Efficacy of Interpersonal Psychotherapy on Major Depressive Disorder, Alexithymia and Emotional Disclosure

*Musfirah Nasr Chaudhry

Bahria University, Lahore, Pakistan

Urooj Sadiq

Bahria University, Lahore, Pakistan

The aim of the study was to investigate the effectiveness of Interpersonal Psychotherapy in dealing with issues of alexithymia and emotional disclosure in individuals with Major Depressive Disorder (MDD). Experimental research design was used. The sample for the current study was comprised of 40 participants diagnosed with MDD with age range of 18-35 years (M=29.18, SD=8.90) from different hospitals of Lahore city who were divided into experimental and control groups with 20 participants in each group. Patient Health Questionnaire (PHQ-9) (Kroenke et al., 2001), Bermond-Vorst Alexithymia Questionnaire (BVAQ) (Vorst & Bermond, 2001) and Distress Disclosure Index (DDI) (Kahn & Hessling, 2001) were used to measure MDD, alexithymia and emotional disclosure, respectively. In order to analyze results, descriptive analysis, linear regression analysis, and paired sample t-test were used for the current study. The summary of results showed that alexithymia is significantly predicting lack of emotional disclosure in individuals with MDD. There was a significant post test difference between experimental and control group on studies variables. It was also indicated that both groups are likely to have significant difference on the studied variables on post testing.

Keywords: interpersonal psychotherapy, alexithymia, emotional disclosure, major depressive disorder

Recognizing and understanding one’s as well as other’s feelings is the key to successful communication. The inability to express and share can cause chaos in human life and can cause different psychological issues like MDD, anxiety, aggression, and low self-esteem (Honkalampi et al., 2010; Zech & Rimé, 2005; Klein, 2002). World Health Organization (WHO) reported that approximately one twenty-one million individuals suffer from MDD worldwide (WHO, 2008). The average incidence of MDD diagnosis is 33.62% (n=2658) in Pakistan (Mirza & Jenkins, 2004). The findings about occurrence of MDD are on the basis of local medical institution studies in all provinces of Pakistan including Punjab: 8% urban, 9% rural, Sindh: 60% urban, 12% rural, NWFP: 5% urban, 3% rural, Baluchistan: 40% urban, 2.5% rural (Gadit & Mugford,2007).

MDD can cause emotional difficulties in life. Emotional difficulties can be best expressed in the trend of alexithymia (Mul et al., 2018; Wittchen & Jacobi, 2005). Alexithymia is characterized by the features such as: “(a) issue in describing feelings; (b) issue in characterizing between feelings and therefore the bodily sensations that accompany emotional arousal; (c) lack of introspection; (d) social conformity; and (e) impoverished fantasy and poor dream recall” (Taylor, 2000). There is an association between alexithymia and interpersonal problems in general population, including social segregation, insecure attachment, and maladaptive behaviors (Fonagy, et al., 2002). Alexithymia can also be considered as limited use of emotional expression. Furthermore, it influences social associations due to problems related with distinguishing feelings, emotions and thoughts (Allen & Heaten, 2010; Klein, 2002; Valdespino et al., 2017).

According to researches by Grynberg et al., (2012) and Cook et al., (2013), alexithymia is linked with lower level of emotional expression and communication. Results of the studies showed that emotional disclosure is initial ground for emotional regulation and handling with pressure (Kahn et al., 2012). Several studies showed that person high in alexithymia determine reduced uttered articulateness; both for affirmative and destructive feelings (Murphy etal., 2018; Watters et al., 2016; Wagner & Lee, 2008).

Individual may depict these emotional difficulties like alexithymia after some stressful situation due to inability to cope and express emotions which may lead to serious diagnosis of psychological disorders. Identification of emotional issues in disorders like MDD can be helpful in treating the individuals as the baseline of the problem lies at the level of thoughts and emotions. To deal with this emotional arduousness in MDD, therapeutic treatment can be most helpful as compare to pharmaceutical treatment. According to research by Ogrodniczuk et al. (2011), it was suggested that alexithymia can be improved with therapeutic treatment and can result in increased ability of emotional expression.

The current study focused on Interpersonal Psychotherapy (IPT) for treating emotional difficulties of alexithymia and emotional disclosure in conditions like MDD (Law, 2018; Weissman, et al., 2000). For instance, Becker-Stoll and Gerlinghoff (2004) examined the effects of a 4-month day hospital treatment on alexithymia levels in a sample of 47 individuals diagnosed with MDD. The treatment program was multi-modal, including psycho-education, cognitive behavior therapy, and interpersonal therapy. Across diagnostic groups, participants who completed the treatment reported significant reductions in alexithymia.A study by Wei et al. (2005) also determined that emotional disclosure improves after interpersonal psychotherapy in both individual and group form. Another study by Smyth et al. (2001) showed that individuals’ emotional expression or disclosure of the individuals improves after interpersonal psychotherapy. This therapy focused on individual specific problem areas, among the four areas of interpersonal psychotherapy (IPT) i.e., grief, role dispute, role transition and interpersonal deficit. By focusing on particular areas, therapy can improve emotional and expressive difficulties in individuals (Murphy et al., 2012). IPT conceptualizes depression as containing three components: “symptom formation, social functioning, and personality”. IPT addresses symptom formation and social functioning, with the goal of dropping out depressive symptoms and increasing social relations, whereas clearly stating that it doesn't commit to amend personality (Schramm, 2020; Weissman, Markowitz, & Klerman, 2000). As a mono-therapy for adults, individual IPT seems to be an efficient treatment for depression (Hollon & Ponniah, 2010).Therapist can focus on one or two of these areas depending upon the nature of the problem of the individuals experiencing psychological issues and can follow the goals and strategies of that particular area or areas. Among the four areas of IPT, interpersonal deficit is most common among the individuals with MDD along with either of the other areas which need not to be necessarily present altogether. But still any area can be focus of attention for depressive individual as all these areas play important role but keep on varying depending upon the nature and extent of the issue. The therapist can therefore focus on particular area or areas for treatment of the individual (Murphy et al., 2012 & Weissman et al., 2000).

IPT is an effective for individuals diagnosed with MDD based on the previous literature (Hollon & Ponniah, 2010, Murphy et al., 2012 & Weissman et al., 2000). Since, insufficient literature is available in Pakistan regarding interpersonal therapy related to alexithymia and emotional discourse so, the current study will be a contribution to literature in this respect. This would be most helpful for treating the individuals with emotional disorders and depressive disorders as it would enhance the ability to express and to distinguish thoughts and feeling by focusing on particular problem areas which can reduce stress and increase coping in individuals(Murphy et al., 2012 & Weissman et al., 2000).

Objectives of the Study

• To determine the alexithymia as predictor of emotional disclosure in individuals with
• To explore the differences in MDD, alexithymia, and emotional disclosure before and after IPT.
• To determine the differences in MDD, alexithymia, and emotional disclosure between experimental and control group.

Hypotheses of the Study

• Alexithymia would predict lack of emotional disclosure in individuals with
• There would be a difference in severity of depression in individuals with MDD before and after IPT.
• There would be a difference in level of alexithymia and emotional disclosure in individuals with MDD before and after IPT.
• There would be a post test difference between experimental and control group on the variables of alexithymia, emotional disclosure and MDD.

Method

Research Design

The experimental research design was used for the current study.

Sample

The sample for the current study was comprised of individuals diagnosed with Major Depressive Disorder (MDD) from different hospitals of Lahore city and researcher further confirmed the diagnosis by using Patient Health Questionnaire (PHQ-9). The severity level of the participants were matched by using Patient Health Questionnaire (PHQ-9) to reduce the confounding variables in the study. Initially, 75 individuals were approached for conducting the study. After careful revision of the data, only 40 participants with MDD were included and divided into experimental and control groups with 20 participants in each group. Maximum efforts were made to match both groups on the demographic variables like age, education and socio-economic status to reduce the disparity in the sample. Both males and females with age of 18 to 35 years (M=29.18, SD=+8.90) who shows depressive symptoms for about two weeks to six months were included in the study. The individuals were with basic education of at least primary for the understanding of the concepts and statements of questionnaires. The individuals were on medications and they were not taking any other psychotherapeutic treatment. Individuals who have other medical conditions or co-morbidities were excluded from the study.

Assessment Measures

Following instruments were used to study and measure the variables.

Demographic Information Form

A self-prepared demographic form was used to get information about age, gender, education, occupation, marital status, duration of marriage, no. of children, no. of siblings, birth order, residential area type, family structure, monthly household/income, and no. of family members. This includes information about parent’s marital status, education and occupation. This form also included age of onset of illness or symptoms, duration of illness, duration of treatment, type of treatment, information about current medications, relapse of symptoms or illness, medical history and family history of psychological illness.

Table 1

Summary of Demographic Characteristics of Sample

Note. N=40 (n=20 for each condition). Individuals were on average 29.18 years old (SD=8.90).

Patient Health Questionnaire (PHQ-9; Kroenke, et al., 2001)

Each of the 9 questions of the PHQ-9 was evaluated on a 4-point rating scale, starting from 0 (not at all) to 3 (nearly every day), and a cumulative score of each participant was calculated. MDD is reflected on it if the score was equal to or greater than 10. Results from the interviews showed that people scored high (≥ 10) on the PHQ-9 were between7 to 13.6 times more likely to be diagnosed with MDD by the skilled professional. On the other hand, people having low score (≤ 4) on the PHQ-9 had chance of one in twenty-five of getting MDD. The urdu translated version of this scale was utilized in this study which had same scoring and cut off procedure as the English version. The Cronbach alpha of the scale computed in current research is .87.

Bermond-Vorst Alexithymia Questionnaire (BVAQ; Vorst &Bermond, 2001)

The BVAQ consists of 5 subscales of eight items each. The 5 factors are: (a)Verbalizing

(b) Fantasizing (c) Identifying (d) Emotionalizing and (e) Analyzing. Respondents react to those statements on a 5 point response scale (ranging from 1= “this in no way applies “to 5= “this definitely applies”). The translated version by Naz and Mahmood (2013) has been used in the current study. The Cronbach alpha of the scale computed in current research is.88.

Distress Disclosure Index (DDI; Kahn & Hessling, 2001)

A 12 item, uni-dimensional self-report measure, is meant to assess the overall tendency to disclose personally distressing information. Individuals’answers to the twelve items are summed with 6 items requiring reverse marking. Higher scores indicate the tendency to disclose distress whereas lower scores indicate a better pattern of distress concealment (Kahn & Hessling, 2001). This reliability analysis resulted a mean of .92 for internal consistency and a mean of .80 for test-

retest reliability (Kahn et al., 2012). The scale was translated for the current study and Cronbach alpha of the scale is .52.

Procedure

After all ethical considerations, approval of conducting research by Graduate Research Committee was attained. The permissions were obtained from respective authorities in hospitals to conduct the research. After permission from authorities in hospital the individuals were then informed about the nature of the research and their permission was taken by informed consent form. The research was comprised of pre-test and post-test format. In this format, the assessment measures were administered before therapy and after therapy to determine the efficacy of this therapeutic treatment. Then those individuals were divided into two groups. These groups were experimental and control group with 20 individuals in each group. Maximum efforts were made to match these groups on the basis of age, education and socio-economic status to reduce disparity in the sample. The control group was given no intervention of psychotherapy and was on their regular medications whereas the experimental group was given the treatment of Interpersonal Psychotherapy (IPT) along with their medications. The individuals in control group were assured that they would be given therapeutic treatment after completion of research. The individuals in experimental group were then given treatment of interpersonal psychotherapy (IPT) in 12-14 sessions which were provided according to the guidelines given byWeissman et al. (2000). Questionnaires and therapeutic treatment was administered in individual setting/room on individuals as it reduced the social desirability bias in individuals. Homogenous setting was maintained for every participant.

The initial phase of IPT lasts more or less 3 to 4 sessions. The goals for this beginning stage embody taking history of episodes of MDD to find out the original cause of matter and categorizing the problem area. IPT for interpersonal issues of 4 problem areas: “grief, interpersonal role disputes, role transitions and interpersonal deficits” were covered in this phase through different techniques. These specific techniques which were utilized in IPT, particularly throughout the middle phase, include: “exploration and clarification, encouraging and identifying affect, communication analysis, decision analysis, and role playing” (Weissman et al., 2000).

The termination phase (approximately 3 to 4 sessions) is the last part of treatment in IPT. There were two aims: “the primary being to confirm that the changes created in treatment are maintained and therefore the second being to attenuate the danger of relapse within the long run”. Termination involves “reviewing therapeutic gains, distinguishing potential triggers of latest mood episodes and developing a preventive plan, graduating from treatment, addressing non-response (if necessary), creating applicable referrals, and discussing the choice and advantage of maintenance, continuation, or booster sessions” (Weissman et al., 2000).

At the end of treatment, the individuals in experimental group were asked to fill the MDD, alexithymia and emotional disclosure questionnaires as post-testing to check the effectiveness of therapy. The individuals in control group were also asked to fill the MDD, alexithymia and emotional disclosure questionnaires after the same duration as that of experimental group. The control group was then provided with therapy after research has ended. The individuals and higher authority of hospitals were then thanked for their cooperation and their precious time.

Ethical Considerations

Authority letters from the institute was taken to hospitals explaining the nature of the research and signed by supervisor to indicate authentication of research. An informed consent was signed by each participant and questionnaire was presented to the individual who met the criterion of research. Attempts were also made not to harm the person emotionally, physically and psychologically. Results were reported complying with ethical considerations. Assurance was provided to individuals of the research regarding the information privacy and confidentiality that it would not be used for any other purpose other than this research. Paticipants were also given the right to withdraw at any moment.

Results

Table 2

Psychometric Properties of Major Constructs of the Study

Note. PHQ= Patient Health Questionnaire, BVAQ=Bermond Vorst Alexithymia Questionnaire, DDI=Distress Disclosure Index

Table 3

Linear Regression Analysis with Alexithymia as Predictor of Emotional Disclosure in Individuals with MDD

Note. *p< .05. **p< .01, ***p <.001

Results of linear regression analysis for individuals with MDD reflects that alexithymia explains 24% variance in the scores of emotional disclosure in individuals with MDD as F (1,38)=12.01, p<.01. Thus, alexithymia significantly predicts lack of emotional disclosure in individuals with MDD.

Table 4

Paired Sample t-Test indicating the difference in MDD, Alexithymia and Emotional Disclosure Before and After Intervention

Result indicated that there is a significant difference in severity of MDD before and after intervention. Results show significant decrease in the level of MDD after intervention. It also

indicated that participants reported significant decrease in alexithymia after intervention program. There is a significant difference in level of distress disclosure before and after intervention as seen in table 4. Result shows significant increase in emotional disclosure after interpersonal psychotherapy.

Discussion

The current research focused on investigating the efficacy of interpersonal psychotherapy in individuals with MDD particularly facing the problems of alexithymia and emotional disclosure. The study hypothesis of alexithymia predicting lack of emotional disclosure correlate well with previous literature which depicts that individuals who are high in alexithymia cannot successfully identify and process their emotions and therefore, are unable to communicate their emotions effectively (Valdespino et al, 2017; Mul et al., 2018; Sorsoli et al, 2008 & Solano et al., 2003).

In the current research, most of the individuals who were high in alexithymia reported that they feel difficulty in disclosing their thoughts and feelings to others as they face problems in understanding the emotions of others and social cues because they are unable to regulate their emotions. Even if they want to disclose their emotions they cannot because they feel distant and detached from others which made them depressive and anxious about their feelings. Most of the individuals in current research also reported that they want to disclose their feelings despite their negative experiences because they sometimes experience extreme emotions but they are unable to relate their emotions with their action as they cannot act in a balanced way. They would either perceive a sad moment as a more negative event as compare to others which cause instability in their expressions and they become unable to understand how to react.

Result of Paired sample t-test indicated that that there was a significant difference in level of MDD, alexithymia and emotional disclosure before and after intervention of Interpersonal Psychotherapy (Law, 2018; DiMascio & Weisman, 1979). These results correlated well with results of current research results in which the participants’ severity level of MDD was reduced after therapy. With IPT, they became able to differentiate between sad reactions to bad news and clinical depression. Individuals reported that their depression was reduced because they understood their idiosyncratic symptomatology and were also educated about the management of each symptom.

Previous research (Rieger et al., 2010) as well as current research interpersonal issues or attachment issues can lead to having difficulties in managing stress and emotions. Interpersonal therapy enables the indivudials to deal more effectively with their interpersonal problems and distressful situations.

Another study showed that individuals’ emotional expression or disclosure improves after interpersonal psychotherapy as individuals learned ways of expressing emotions when they need it instead of keeping them to themselves and suffer from various problems or clinical disorders (Smyth et al., 2001). According to research by Ogrodniczuk et al. (2011), it was suggested that alexithymia can be improved with therapeutic treatment and can result in increased ability of emotional expression. These findings relate with results of the current study in which the level of emotional disclosure of individuals increases after the intervention of interpersonal psychotherapy. Individuals in current research shared feelings of a need to be understood by others and reported that focus on their expression helped them to cope with the situation. Findings of the current study showed that this treatment has been effective on indicators of emotional expressiveness, emotional sensitivity, emotional control, social control and social

expressiveness of the experimental group. Overall, interpersonal therapy helps individuals to learn to enhance their understanding toward people in their living environment. It̕ s significance can be attributed to social skills training and increased knowledge about emotional regulation among the participants of the study.

Conclusion

The findings of the present study revealed that alexithymia is likely to predict lack of emotional disclosure in individuals with MDD. The findings also suggested that interpersonal psychotherapy reduces interpersonal problems. Therefore, alexithymia is improved and the therapy also helped individuals to express in appropriate manner. Therapeutic treatment helped the individuals in experimental group in understanding the individual, family and environmental factors. The control group was not able to cope with problems because their problems were left unattended. It can therefore be inferred that interpersonal psychotherapy is the effective therapeutic treatment for emotional problems and mood disorders like MDD.

Implications

The implications of the present study involve the effectiveness of interpersonal psychotherapy. This treatment of interpersonal psychotherapy will be helpful for MDD and other interpersonal issues of individuals. Its effectiveness was also confirmed by testing the research variables before and after therapy. This research would also be helpful to therapists for the treatment of MDD and can also be a guideline for researchers. This research would be most helpful for treating the individuals with emotional disorders and depressive disorders with interpersonal and other psychotherapies as it would enhance the ability to express and ability to distinguish thoughts and feeling by focusing on particular problem areas which can reduce stress and increase coping in individuals.

Due to scarcity of literature in the area of interpersonal therapy in Pakistan, the current study will be a contribution to literature. The current research can help future researchers and psychologists to understand and manage the emotional and interpersonal problems of individuals with MDD.

This research can help in executing psychotherapy training programs and workshops. These training programs and workshops can be provided to therapist working in hospitals including trainee therapists, university students, teachers and supervisors who directly provide psychotherapy and other counselors in various fields who provide psychotherapy to indivudials with psychological issues. These training programs should include criteria of therapy, client- therapist issues, and relationship factors should be covered, as well as the many different approaches to studying the effectiveness of the psychotherapies. Manuals and practice guidelines are useful tools for teaching trainees the basic theoretical and technical orientations associated with different therapies particularly interpersonal psychotherapy keeping in view the current research.

Limitations and Recommendations

The first limitation of the current research was that it only involved the emotional factors contributing to the presenting issues of individuals. The current study is not focused on investigating the other factors of individuals contributing to MDD as well in relation with interpersonal psychotherapy. Therefore, further researches should involve other aspects like cognitive and behavioral etc contributing to MDD as well.

In current research, the sample size was small to generalize our results. The 40 individuals were taken and only 20 were given intervention of interpersonal psychotherapy. Further researches should be conducted by involving the large sample size for intervention. Interpersonal Psychotherapy for individuals with depression was used in the current study. Interpersonal Psychotherapy for other disorders like Post-traumatic disorder, anxiety and eating disorders should be used in future researches and then the comparative studies can be conducted to study the effectiveness of therapeutic treatment like interpersonal psychotherapy.

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Contribution of Authors