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A Novel Therapy

Aware by VeVi… for a Well-known Problem

Dichelle Wong and Jane Morris discuss the use of interpersonal therapy with an elderly client presenting with challenging physical and psychological issues.

A patient referred with anxiety and depression seemed like an everyday case for a psychotherapist. The patient’s actual complaint was her waterworks (urinary incontinence). As her therapist, and in order to treat the problem of the incontinence, I eventually used skills of Interpersonal Therapy (IPT) and drew upon principles from Cognitive-Behavioural Therapy (CBT), Psychodynamic Psychotherapy, Cognitive Analytic Therapy, Dialectical Behaviour Therapy and Systemic Therapy, in addition to prescribing medication. I found this to be an interesting, thought-provoking experience that illustrates the challenges one can face when treating elderly patients with psychiatric/psychological illness in the presence of physical co-morbidity.

IPT is a structured and time-limited therapy usually comprising twelve to twenty sessions. The patient’s problems are formulated in interpersonal terms, and treatment is provided using one of four foci (grief, role disputes, role transitions or interpersonal deficits) (Klerman, 1984). I made use of group supervision under the guidance of Dr Jane Morris.

Betty was an 83-year-old divorced lady who lived alone and was independent in her activities of daily living. She described a happy childhood and at twenty-three years old, she got married and gave birth to a daughter. Betty was divorced after eleven years due to her husband’s problems with alcohol. She worked as a store manager. After retirement, she led an active social life and continued to work in a museum until she was 73 years old. She did not have any previous history or family history of psychiatric illness. She suffered from hypertension and mild chronic obstructive pulmonary disease.

In March 2008, Betty felt light-headed and shaky. She had multiple medical investigations and the conclusion was that the event was not suggestive of cerebro-vascular disease. However, Betty’s self-confidence was severely affected and she became hyper-vigilant of physical symptoms. Furthermore, a series of adverse events happened: she became anxious after she was mugged and she was troubled by anti-social behaviour in her neighbourhood; Aware by VeVi 3some of Betty’s elderly friends and neighbours died and her flat was flooded by a leak from the upstairs neighbour. She started to suffer from poor sleep, low mood and panic attacks. Betty’s daughter invited her to stay with her and her husband temporarily while her flat was being redecorated.

Betty was initially referred to the psychiatry team by her GP for treatment of anxiety. Citalopram, Zopiclone, Diazepam and Mirtazapine did not help. She was assessed at the psychiatric day hospital and was diagnosed with mixed anxiety and depressive disorder. However, her symptoms of distress and anxiety became unmanageable at her daughter’s home and she was admitted to an old age psychiatry ward in January 2009.

In the hospital, investigations were mostly unremarkable. A CT brain scan showed moderate generalised atrophy, mild small vessel ischaemic changes normal for her age. There were no clinical signs of dementia. Her Mini Mental State Examination score was 27/30 and her Addenbrooke’s Cognitive Examination (revised version) score was 80/100. She had full scores in memory, attention and orientation subsections.

Betty was reviewed by a consultant urologist who thought she had an overactive bladder; however flexible cystoscopy showed no bladder abnormalities. She was preoccupied with urinary incontinence symptoms and found it very embarrassing to have waterworks problems and to have to use incontinence pads. She feared that she would have an accident of wetting her trousers and was very anxious especially in the mornings. She clutched her nightdress, would not take it off to get washed or dressed and would not allow the nurses to help her. It took at least two hours each morning for her to finally get washed and dressed. This was also the difficulty experienced by Betty’s daughter prior to hospital admission.

Betty spent nine months in hospital and her anxiety and depressive symptoms proved very hard to treat. Venlafaxine XL was started in April 2009 and the dose was increased gradually to 225 milligrams over a five-month period. She received psychology input on our ward. After a few sessions, the clinical psychologist found that she was quite reticent and did not access her cognitions for the CBT work that was needed. The psychologist then tried to work with the nursing team on a behavioural programme for Betty, aiming to distance her from the toilet, but she did not get involved in this. The psychologist felt that IPT would be a good way forward since she had difficulties with interpersonal relationships.

Interpersonal Therapy for Betty
Betty received twenty sessions of IPT from me. The first eight sessions were held in the old age psychiatry hospital ward. The remaining sessions took place at her daughter’s home after hospital discharge.

Initial Phase (Sessions 1-4)
I explained to her what IPT was and took a detailed history from her. I gave her the ‘sick role’, that is, I explained that depression is a medical condition that requires addressing and treatment in its own right. I educated Betty about the diagnosis of mixed anxiety and depressive disorder. Her Hospital Anxiety and Depression Scale (HADS) score was 19 for anxiety and 15 for depression prior to therapy. We drew up an interpersonal inventory showing all the people that were in her life.

Betty was not interested in the IPT sessions since she did not see how they could help her problem. Interestingly, she started to engage better after I took a strong interest in her incontinence by teaching her pelvic floor exercises, which I had to learn from the physiotherapist. Incorporating pelvic floor exercises into IPT sessions resulted in an unexpected breakthrough in therapeutic rapport.

Middle Phase (Sessions 5-15)
With her permission, I invited Betty’s daughter and son-in-law to join us in Session 6. She and I drew a time line of events throughout her life. I chose ‘role transition’ as the IPT focus as she had undergone multiple transitions within seventeen months. She had remained in her home town for over 80 years before going to stay temporarily with her daughter in a different city; she then went into hospital for nine months, planning to return to her daughter’s home while waiting for sheltered housing.

We discussed the impact of each transition and her feelings about them. We also anticipated difficulties for her pending the move to sheltered housing and she identified family members who would be able to help her with practical difficulties. We spoke about how it was possible to transfer good activities or things that she enjoyed from her home town to her new home.

IPT facilitated the assessment of her symptoms, her social situation, her views and wishes, in addition to the provision of therapy. Betty explained to me that she worried that as soon as she sat upright, her waterworks would start and she would wet her nightgown, so she refused to leave the house for fear of having an accident.

Aware by VeVi 2

Betty often complained that the incontinence pads did not work very well and were not absorbent enough. I used the CBT technique of analysing her cognition (automatic thoughts and assumptions) and I tried to challenge her dysfunctional and irrational thinking, but this did not work. She was resistant to suggestions of alternative ways of looking at things.Together we performed a behavioural experiment where I poured water onto a pad in front of her and her daughter. The pad soaked about 500 millilitres of water without leaking, even when it was squeezed or held upside down. However, Betty said she was still not convinced that the pad would not leak urine when she was wearing it. She was adamant that she was feeling bad and it had to be due to her problem. This was consistent with emotional reasoning; Betty felt that if she did not have to use pads, everything would be fine. I reduced the dose of Furosemide to 20mg and Betty’s daughter said there was a dramatic improvement in her urinary symptoms; there were hardly any wet pads throughout the day, and she no longer showed signs of urgency. However, she again denied that the waterworks was better. She attributed the lack of accidents to ‘being lucky’.

With Betty’s permission, I met with her son-in-law. There had been a suggestion from colleagues that there might have been, in psychodynamic terms, projection and splitting which, as it happened, turned out to be true. Betty projected her feelings about her ex-husband on to her son-in-law. He was extremely frustrated with the whole situation, and thought she should not stay at their home any more as she caused arguments that were damaging his marital relationship.

Termination Phase (Sessions 16-20)
The frustration between Betty, her daughter and son-in-law was increasing to the point that they found it intolerable to have her at their home. Betty admitted to insulting them and there were many arguments. She also refused to comply with any of my suggested therapeutic interventions (such as changing to an alternative anti-depressant, adding an anti-cholinergic medication or trying a behavioural programme) but insisted that she was complying.

By this point, Betty was in despair; she was argumentative and I felt I was running out of options as to how to help her. She spoke to me about her advancing age and death awareness, and worried that she would not see her grandchildren grow up. After that session, I felt an intense sadness and kept on getting the feeling that she would not survive the week. I felt an immense anxiety that I would knock at her door for the next session and someone would tell me that she had passed away. It became clear during group supervision that her despair and anxiety about death and aging was being projected on to me, and that I was experiencing very powerful counter-transference.

The focus of the IPT sessions changed to ‘role dispute’, since Betty was in dispute with all those who were trying to help her (her family members, her carer and her therapist). The following sessions were designed to help her resolve or avoid conflict. I found out that she used to maintain good relationships with her family members and friends and discussed ways by which she could try to repair those relationships.

Eventually a sheltered housing offer arrived but Betty and her daughter turned it down during the visit since they felt the flat did not match their expectations. Since sheltered housing offers were not easy to come by, I spent some time in one session helping her practise thinking through the advantages and disadvantages after seeing a flat, in preparation for the next offer. I advised her not to turn down a flat immediately if it was not perfect but to go home and have a family discussion to see if there were ways that would compensate for the shortfalls of a particular flat. ‘Chain analysis’ of difficult situations and distress tolerance was applied.

A second flat became available for viewing. Although Betty thought it was not ideal in that it was not close to shops and it was very run-down, after a discussion with her family, she accepted it. She said she could rely on her family to do the shopping and they would help with the renovation of the flat. She started to go outdoors (for four hours on one occasion) to visit her family or go to the shops with her daughter. She did not have any accidents during those times.

Betty and I spent a session talking about loss: the loss of her flat in her home town, her life in her home town, her deceased friends and family members, her therapist, loss of her role, and the ‘good old Betty who was without waterworks problems’. We also spent time talking about what good things from her past could be transferred to her new way of life, including spending time on her hobbies. During the second-last session, I introduced her to the community psychiatric nurse who would be monitoring her mental state and providing support to her once IPT was completed.

At the final session, Betty scored 13 on anxiety and 9 on depression on HADS. These scores were lower compared to scores done prior to IPT, consistent with the improved clinical picture. Borrowing an idea from CAT, I wrote a goodbye letter so that she could read about my views on her good progress and be able to refer to the letter again in future for support. I also wrote a letter to her daughter and son-in-law, thanking and commending them for their support of their mother during a very testing period. I read out my letter and Betty listened with interest and told me that the letter was very nice, but she felt she did not deserve it. She was tearful and told me that she wished I did not have to go. We hugged and made our farewells.

After IPT therapy was completed, Betty’s community psychiatric nurse reported that she had successfully moved into a sheltered housing flat close to her daughter, and was managing to go outdoors for lengthy periods of time without any accidents. Although Betty still talked about waterworks problems, she appeared bright and relaxed, and positive in her outlook for the future.

Discussion
IPT has been shown to be useful for late-life depression, and does not require major modification when used in the elderly population (Miller, 1998). It has been demonstrated to be effective for treating recurrent major depression in the elderly when used alone on a monthly basis and when combined with antidepressant medication (Miller, 2001).

In this instance IPT was very useful as Betty could not co-operate with CBT or a behavioural programme. Her case illustrated the complexity of managing an elderly person with psychiatric, physical and social issues. It was a challenge to liaise extensively and regularly with the multi-disciplinary team, her GP and her daughter. (Confidentiality was respected at all times and prior consent was sought).

I also wish to highlight that occasionally, when symptoms seem to be resistant to treatment, the therapist may repeatedly need to examine and modify the formulation, seek suggestions from colleagues and adapt the therapy to suit the patient.

Dichelle Wong is an Old Age Psychiatry Specialty Registrar at the Jardine Clinic, Royal Edinburgh Hospital.
Jane Morris is Consultant in Child and Adolescent Psychiatry, Child and Adolescent Mental Health Service at the Royal Edinburgh Hospital.

References
Klerman, G. L., Weissman, M. M., Rounsaville, B. J., Chevron, E. S., (1984), Interpersonal Psychotherapy of Depression. Northvale, NJ: Jason Aronson Inc.
Miller, M. D. et al., (1998), Using Interpersonal Psychotherapy (IPT) in a Combined Psychotherapy/Medication Research Protocol with Depressed Elders: A Descriptive Report with Case Vignettes. Journal of Psychotherapy Practice and Research, 7, pp.47-55.
Miller, M. D. et al., (2001), Interpersonal Psychotherapy for Late-Life Depression. Journal of Psychotherapy Practice and Research, 10, pp.231-38.

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