Mr. A, a 42-year-old Japanese male patient, suddenly lost his mother to heart disease. She had lived alone with his father and had suffered from a non-cardiac chronic physical illness for >5 years before her death. The patient had been concerned about his mother's health since she was first diagnosed with the disease and routinely kept in touch with her by phone. Approximately two years before her death, his mother began to lie in bed complaining of poor health, but until the day before she died, she could still go about daily life without major assistance. On her final day, his mother suddenly collapsed on the toilet. Taken to a hospital, she subsequently died.
Mr. A exhibited acute grief. He did mourn privately. He told no one at work about his mother's death, and he mourned so invisibly that they were unaware of his grief. "The hardest thing is that I have no one at all to share my grief with," "I can't concentrate at work and I'm in a daze at home," "I have a feeling of emptiness in life," he said. He felt suicidal and excessively guilty. Specifically, he thought that life was not worth living and actively planned to die; it was not just the thought that death could reunite him with the deceased in the afterlife. Thoughts about the death of the deceased and "joining" the deceased can be part of normal grief, but his thinking involved ending his own life because of feeling worthless, undeserving of life, and too guilty. He had a reduced appetite and insomnia. He kept everything inside, which was a set-up for complicated bereavement. Eight months after the death, he was diagnosed with bereavement-related MDD (DSM-5) at a mental health clinic. On the Beck Depression Inventory-II (BDI-II), his depressive symptom severity score was 43. The patient received antidepressant pharmacotherapy with mirtazapine and escitalopram. Aripiprazole 1.5-3 mg was started as augmentation but immediately discontinued due to akathisia. Two months later, the prescribed medication (mirtazapine 15 mg and escitalopram 10 mg) had only slightly decreased his severe symptoms (BDI-II = 37).
Mr. A visited our hospital to receive IPT for bereavement-related MDD. He was the only child of a homemaker mother and an employed father. His mother was the primary person with whom he had emotional exchanges and casual conversations. He did not emotionally communicate with his father, who had abused alcohol since the patient's childhood. After graduating from a science graduate school, Mr. A became a company employee. He was married and had two children. His wife provided cooking and cleaning and met his other physical needs but was not emotionally close.
Assessed using the Mini International Neuropsychiatric Interview at our hospital, Mr. A was diagnosed with DSM-5 MDD. After careful examination, persistent complex bereavement disorder (PCBD) in DSM-5 Section III (recently superseded by prolonged grief disorder in the Diagnostic and Statistical Manual of Mental Disorder 5th Edition Text Revision (DSM-5-TR)) could not be diagnosed because (1) functional impairment was attributed to MDD and (2) the 12 months required for PCBD diagnosis had not yet passed. His depression, which appeared to have been triggered by his mother's death, worsened whenever he felt alone and sad without his mother, exacerbating his grief.
He stated that his mother was someone he understood so wholeheartedly that no one could ever replace her. He blamed himself intensely for not taking steps to prevent his mother's death, such as suspecting cardiac problems and recommending that she go to a hospital before her death. He thought about her constantly, to the point that it interfered with his work and family life. Meanwhile, he avoided looking at pictures of his mother or visiting places where he had often spent time with her. He constantly avoided expressing and sharing various emotions, including grief. The Japanese cultural tendency to avoid publicly expressing grief in daily life seemed to compound his emotional avoidance, bringing greater levels of grief and depression severity.
Mr. A had to deal with his father's alcoholism and associated problems. His father, left alone after the mother's death, fell after drinking and had to be taken to the emergency room. Mr. A's estranged relationship with his father exacerbated his depression. Thus, his bereavement-related MDD seemed sustained not only by his mother's death but also by a dispute with his father.
The patient received 16 IPT sessions, each lasting 60 minutes. Sessions were conducted once weekly or once every 2 weeks. The first author (YT) delivered the treatment, having been trained by and in supervision with HM, an International Society of Interpersonal Psychotherapy (ISIPT) certified trainer/supervisor. The patient continued stable doses of mirtazapine 15 mg and escitalopram 10 mg. He completed the 21-item BDI-II self-report measure at baseline, immediately after, and three months after treatment. BDI-II total score ranges from 0 to 63, with higher scores indicating more severe depressive symptoms. A score over 29 is considered severe depression.
The therapist aimed to establish a therapeutic alliance, using verbal and nonverbal communication to establish a rapport with the patient. She conducted IPT for bereavement-related MDD, focusing on grief and the interpersonal role dispute with the father, following a published treatment manual.
First, to facilitate the grieving process, the therapist encouraged the patient to express how he had felt before and after his mother's death. The therapist did this through encouraging his participation in Japanese postbereavement rituals, such as funerals and memorial services, especially after a mother's death. It was psychologically easier for the patient, who avoided expressing and sharing grief generally, to express grief during Japanese cultural rituals than in daily life. In the rituals, he repeatedly expressed the sadness, pain, and loneliness of not having his deceased mother by his side.
Second, the therapist encouraged the patient to consider a Buddhist memorial tablet, altar, and a grave, through asking him about recent topics relating to his deceased mother. Mr. A was a practicing Buddhist and the therapist integrated Buddhist spiritual beliefs that the deceased exist as a soul in the afterlife and that one can have a relationship with the deceased through the Buddhist memorial tablet, altar, and grave into the sessions in order to help the patient deal with grief. He decided to make the mourning implements. The therapist explored with the patient his and his mother's mutual expectations regarding the design of the tablet and altar and the location of the grave. Mr. A reported that his deceased mother never replied to him directly anymore and said he would like to reestablish a relationship with her.
Although there were no communication problems with the mother, his strong emotional avoidance made it appear as if there was a gap in expectations in that he had not prepared a tablet, altar, and grave. Mourners generally prepare a tablet and altar by the 49th Buddhist memorial service, and a grave is generally prepared by the 49th Buddhist memorial service or the first or second death anniversary. Therefore, in sessions, in addition to eliciting his expectations of his mother, the therapist used emotional encouragement to elicit her mother's expectations of him in his mind. Mr. A and his mother had not discussed mutual expectations they had about the tablet, altar, and site of her grave before her death. However, Mr. A and his mother had talked about their feelings and mutual expectations about a variety of matters, important and trivial, since childhood, so he felt that over time, they gradually came to know each other's feelings and mutual expectations without exchanging words. Therefore, he could imagine in his mind his mother's expectations of him about the tablet, altar, and gravesite through this treatment. Mr. A thought that his deceased mother expected him to have gentle designed tablets made and to have her grave in a place where she could see her favorite view. Mr. A wanted to live up to his beloved mother's expectations, and the therapist and the patient confirmed that doing these things would resolve any gap in expectations.
He then chose a pleasant, caring design for the Buddhist memorial tablet that evoked a gentle feeling his deceased mother would have liked. He decided to place her grave near his house, which had a view of the landscape she loved, where he could frequently visit with her and her soul could see her favorite view. In Session 10, he said, "Her bones are alone in the grave, but her soul is not lonely and is spending time with those close to her [her deceased father and deceased dog]" when describing having placed his deceased mother's ashes in her grave. He then said that he felt at peace. In Session 11, he felt his deceased mother was close to him and felt calmer when he placed his hands on the home altar with the Buddhist memorial tablet in the morning and evening. He seemed to find a deeper level of comfort in his mother's death and to have reestablished a warm relationship with her.
Third, to enhance social support and counter his depressed social withdrawal, we explored the possibility of having emotional exchanges and casual conversations with his wife or others in order to reestablish interests and relationships. He mentioned having previously felt fulfilled by casual conversations with a close older colleague who had taught him interesting things, and he had felt relieved when talking with that colleague after his mother's death. However, the COVID-19 pandemic precluded frequent in-person meetings with his colleagues. We explored the possibility of talking with his colleague via email and Zoom. In Session 9, Mr. A said he wanted to have a chat with his colleague that was not really work-related (about his colleague's hobbies, his colleague's interesting acquaintances) and could text his colleague to see if they were both in the office on the same day, although office work days were quite low because of COVID-19. Mr. A reported feeling a positive change in his mood after briefly chatting with his colleague during long company Zoom meetings.
Further, the therapist helped Mr. A to explore developing an emotional communication with his wife. It became clear that his wife was a logical thinker and he primarily expected physical support from her. His wife took the initiative to look after the children herself when he was very tired and encouraged him to take morning walks to get fit. He did not fully share his grief over his mother's death with his wife, but he appreciated her concern for his well-being and care for their children when he was not feeling well and wanted time alone. This reduced his anxiety in his relationship with his wife.
As already described, the therapist encouraged Mr. A to facilitate the grieving process while reestablishing a relationship with the deceased mother in the afterlife. When talking about his mother, he did not cry in sessions, but he looked teary-eyed, his speech paused, his facial expression stiffened, and he always made a strong gesture with fists and rubbing his hands. His hard facial expressions and hand gestures, which appeared to be signs of anxiety, gradually improved towards the end of sessions. The therapist did not assign homework: these changes in expression appeared a loosening up of affect with growing trust in the therapeutic relationship.
The patient had been coping with his father's problematic alcoholic behavior alone after his mother's death. He had previously managed this with his mother until he graduated from high school but had not had to do so since entering university in the city where he could pursue his dreams living far from his parents. The patient was angry when his father suddenly again become an unwanted burden for him after his mother's death. There is an expectation that Japanese children care for their widowed parent when the parent is ill, whatever the illness. His father had been admitted to a facility for alcohol treatment one month before the IPT sessions began.
Concerned that his father's drinking might bother others, Mr. A maintained frequent contact with his father and tried to persuade him not to drink. Unfortunately, each contact with his father worsened his depression, who ignored Mr. A's concerns and kept drinking. Mr. A wanted to separate from his father, but the cultural expectation to care for the widowed parent made him guilty. He felt both guilt and strong anger towards his father and recognised that it was natural to have these feelings. However, because he rationally suppressed some of his feelings toward his father, he did not yell at him. Nor did he share his feelings with those around him, including his wife. The dispute was in the stage of dissolution.
The therapist explored with the patient how his father was coping with the loss of his wife, considering the possibility that his father's alcohol use might have increased to drown his sorrow. In fact, his father had rarely spoken to his mother since long before her death, and his attachment to her appeared to be so poor that he did not consider conducting the mother's Buddhist rituals even after her death. These require quite burdensome tasks for the bereaved family: to plan for holding a funeral or memorial services for the deceased and meet with funeral directors and Buddhist monks, but his father did not try to plan for it; he only participated because Mr. A told him to. Thus, the father's grief appeared not as profound as Mr. A had imagined, and his drinking did not obviously increase following the death.
The therapist explored the mutual expectations of the patient and his father and used communication analysis regarding his father's alcohol consumption. Worried that his father's drinking would bother others, Mr. A candidly asked for sobriety. His father rarely expressed his feelings in words, but he seemed to want his son to leave his drinking alone and secretly bought alcohol. The father never met the patient's expectations.
In order to end the relationship between him and his father, the therapist explored with the patient whether he could expect his father to recover from alcoholism and become sober in future. The person's motivation for treatment is crucial for alcoholism prognosis, yet unfortunately, his father had lacked that motivation for years and seemed unlikely to improve. The therapist helped Mr. A talk to his wife about his concern over his father's alcoholism using role play. She advised him to leave his father in the care of the treatment facility so as not to burden the patient. The therapist encouraged Mr. A to ask someone at the facility whether his father was bothering others with his drinking. He was relieved to learn that despite his father's problematic drinking, people at the facility did not consider it a nuisance and were doing their job to cope with it.
Hence, Mr. A was able to adjust his expectations of his father's sobriety:he no longer expected sobriety:and felt he could leave his father under the care of the institution. It helped that his wife respected his emotions. He no longer felt overly responsible for his father's alcoholism, as his father never wanted to stop drinking. His depressive symptom severity no longer progressed because of his relationship with his father.
During treatment termination, Mr. A said: "I have learned to accept the fact that everyone will die one day... I am getting used to life without my mother," "I feel a little calmer now that I have a Buddhist altar," and "I have started to think about watching a variety TV show." The BDI-II, decreasing from 37 (pretreatment) to 23 (posttreatment), supported the patient's perspective of improvement. Although Mr. A still scored in the moderately depressed range on the BDI-II, his appetite and insomnia were improved and he was no longer suicidal or overly guilty. That is, he no longer seemed to be depressed, but rather very sad.
In this treatment, the therapist continued to explore mutual expectations between himself and his deceased mother regarding the relationship with his father. He expressed anger towards his mother at the 2-month follow-up, saying that he had long encouraged his mother to divorce his father, but that she had tolerated him despite his alcoholism, had been unable to divorce him, and had gotten physically ill as a result. At 3-month follow-up, he had started studying English to assist him in his future work. His father had had to be rehospitalized, but he felt he could trust the facility with the hospitalization procedures and felt less psychological burden than before. His BDI-II decreased from 23 to 18 from posttreatment to the 3-month follow-up.