1. Attachment based cognitive-interpersonal psychotherapy for chronic depression Gary A. Sibcy, II, PhD Liberty University

2. Characteristics of Chronic Depression Long-standing history of Dysthymic Disorder with multiple, superimposed Major Depressive Episodes Multiple Major Depressive episodes, each lasting several years Some never fully recover and remain in partial remission Many have comorbid Axis I and Axis II Disorders

3. Typical Treatment History Long periods of untreated depression before seeking first treatment Previously misdiagnosed Antidepressant only at inadequate doses and/or length of treat Those receiving therapy derived little to no benefit Few will have received combined medication and psychotherapy

4. Characteristics of Chronic Depression Highly treatment resistant to nearly all treatment modes: Medication Psychotherapy CBT IPT STDP

5. Normal Mood Variability Ceiling Floo r

6. Ceiling Floo r 2 + year

7. Ceiling Floo r childhood 2+ years

8. Ceiling Floo r 20 weeks

9. Psychosocial Profile History of early—sometimes complex-- relationship trauma//attachment trauma Neurocognitive deficits  Pre-operational thinking  a pre-causal view of world Learned helplessness (Low internal locus of control) Chronic mood dysregulation  does not respond to information/disputation/insight/cognitive restructuring Ineffective, self-defeating patterns of social behavior Submissive IP Style—pulls therapist into dominant role-  recapitulates previous relationships  helplessness

10. Neurocognitive Deficits Chronic dysregulation of lymbic system Elevated cortisol levels Neuro degeneration of integrative neurocircuits linking prefrontal cortex with limbic system— Degeneration of middle frontal areas of the brain and hypocamppus  responsible for attending to and contextualizing relationship events Consequently, person relates in mindless fashion, repeating same old patterns of relationship experiences— Confirms feelings of hopelessness and helplessness

11. Psychological and relational characteristic Poor emotion regulation skills Impaired social functioning Low internal locus of control//negative attributional style Helplessness— “I have very little control over what happens to me”//

12. Characteristics of Chronic Depression Usually combined with history of early onset dysthymia Each MDE last longer, with lower likelihood of returning to normal mood Usually combined with: Heightened social impairment More occupational impairment High rates of comorbidity

13. Major Depressive Disorder

14. Dysthymic Disorder

15. Healing Attachment Through Relationships

16. An Integrative Model of Depression Role Transitions Loss/grief Relationship disturbances Loneliness Type I Type II Genetics/biolog y X Early Relationship Experiences Social-Neuro-cognitive Skill Deficits Insecure Working Models of Attachment X Negative Bias Self Future Other/ world Chronic Mood Dysregulation Behavioral Disturbances Focus Intervention

17. Sample Narrative My husband doesn’t appreciate me. Nothing I do interests him. He cares more about his video games than me. He’s always had sort of an addictive personality…he gets totally absorbed in things…he doesn’t care about anyone but himself…I guess it’s just me. If I try to say something to him about how I feel he just goes off and starts putting me down. It’s useless for me to say anything to him about my feelings. They don’t matter to him.

18. Sample Narrative The other evening I decided to tell my husband my feelings about him spending so much time playing the video game. I told him that I felt he was addicted to the game and even told him there is research on how these games work like addictions. I also told him it was like he had a mistress and I couldn’t stand it anymore. He told me I was overreacting and that I blow everything out of proportion. He told me I needed to get a life and walked off.

19. Integrative Treatment Model Focus on Relationships Enhance Motivation: Will Set Psychoeducation: Self observation Empathy Assertiveness Respect Complete Relationship Event Worksheet Revise Communication

20. Enhance Motivation Will Set Redefine Intimacy— Willingness to endure negative feelings you will get when you get close to another person Decision Making Continue trying to change other Leave the relationship Stay and focus on changing the way you communicate Giving up Blame The need to be right

21. Skill Set #1 Engaging the Observational Self— Hippocampus and Prefrontal Cortex Relationship Events Place, time, context Beginning, middle, end Narrow Focus--Snippet

22. Skill Set #3 The “EAR” Empathy Accurately Acknowledging feelings and thoughts Adding Humility Assertiveness Expressing your feelings and thoughts “when you….I feel Expressing your core needs Respect Bringing out the best Giving benefit of the doubt

23. Back to Susan He/She Said:You Said:He/She Said: You overreact to everything…you blow everything out of proportion I really need to you understand my feelings and take me seriously (Did your statement make things better or worse?) You need to get a life Rate: 0-5 Empathy Assertiveness Respect

25. Dealing with Resistance Two Kinds of Resistance Process Outcome “Its not fair…he’s such a jerk” Modeling EAR

26. Paradoxical Cost Benefit Analysis Magic Botton If you could hit this magic button and your husband made a dramatic transformation, would you hit it?

27. Narrow the Focus: Relationship Snippets He/She Said:You Said:He/She Said: You overreact to everything…you blow everything out of proportion I really need to you understand my feelings and take me seriously You need to get a life

28. Skill Set #2 “Will Set” Redefine Intimacy— Willingness to endure negative feelings you will get when you get close to another person Decision Making Continue trying to change other Leave the relationship Stay and focus on changing the way you communicate Giving up Blame The need to be right

29. Skill Set #3 The “EAR” Empathy Accurately Acknowledging feelings and thoughts Adding Humility Assertiveness Expressing your feelings and thoughts “when you….I feel Expressing your core needs Respect Bringing out the best Giving benefit of the doubt

30. Back to Susan He/She Said:You Said:He/She Said: You overreact to everything…you blow everything out of proportion I really need to you understand my feelings and take me seriously (Did your statement make things better or worse?) You need to get a life Rate: 0-5 Empathy Assertiveness Respect

32. Dealing with Resistance Two Kinds of Resistance Process Outcome “Its not fair…he’s such a jerk” Modeling EAR

33. Paradoxical Cost Benefit Analysis Magic Botton If you could hit this magic button and your husband made a dramatic transformation, would you hit it?

34. CostBenefit

35. Intervention Plan Two Skill Sets Will Set Social Skill Set Redefine Closeness/intimacy Three Choices Stay—status Quo Leave Stay—change communication Give-up: Blame Self-Monitoring Relationship Events Empathy Respect