Interpersonal Psychotherapy for Posttraumatic Stress Disorder

Phase 2.
 Once the patient agrees with the formulation the therapist has 
presented— and this is almost always the case— IPT enters its 
middle 
phase
 (sessions 4– 9). This focuses on treatment of the interpersonal 
focus that the formulation has established. Beginning with the opening 
gambit (“How have things been since we last met?”), the therapist uses 
specific strategies to explore the patient’s feelings in interpersonal 
situations. The strategies differ somewhat for 
complicated grief, role 
dispute, role transitions
, and 
interpersonal deficits
, but the basic issues 
are the same: How do you feel? What does that feeling (or those mixed 
feelings— it’s possible to have more than one) tell you about your 
interpersonal situation? Is it reasonable that you should feel that way, 
given the situation? And if it is reasonable to feel sad/ angry/ anxious, 
what can you do with that feeling? What options do you have? Then 
role- play feasible options to gain comfort in actually using the feelings. 
Again, this frequently involves asserting one’s wishes or dislikes to other 
people.
In 
complicated grief (complicated bereavement)
, a significant other has died 
and the patient has become depressed. The goal is to help the patient grieve 
and begin to move on. Goals of treating complicated grief include:
 • 
Tolerating the affect.
 Many patients in this situation have been 
afraid to grieve, feeling that the affect would be overwhelming and 
destructive. “If I started to cry, I would never stop. I’d crumble.” IPT 
therapists try to normalize affect, allowing catharsis and processing 
of the emotions. Therapist ask about why the lost person and 
relationship were important: “What do you miss about— ? 
…
 What 
do you miss about the relationship you had?” Over time, it is also 
helpful to explore mixed feelings, even though (or more precisely, 
because
) many depressed patients feel awful that they might dislike 
or even hate someone who is dead. “What didn’t you like? 
…
 Every 
relationship has frictions, difficulties
… 
. It’s possible to love and hate 
someone at the same time.”

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A Pocket Guide to IPT 
45
 • 
Regaining a direction.
 Many patients struggling with complicated 
grief find themselves adrift, stuck, empty. They may have stopped 
working at their jobs to care for an ill relative, then find themselves 
without a job as well as without the relationship. As patients start to 
express their feelings and feel better, it’s important to help them find 
other social supports to replace the lost relationship, as well as a new 
purpose and direction in life. Sometimes this relates to the death 
of the other: for example, volunteering for the American Diabetes 
Association.
Patients presenting with a 
role dispute
 are invariably losing a battle in a re-
lationship. The concept of a role dispute is that both members of a relationship 
have needs, likes and dislikes, and they hopefully compromise on these to their 
mutual satisfaction. Depressed and anxious patients tend to avoid confronta-
tion, to see anger as a “bad” feeling, and so tend to submit to the demands of 
others without presenting their own needs and wishes. The goal of treating a 
role dispute is to help the patient (1) recognize that disparities in a key relation-
ship are contributing to the depressive episode, and (2) learn to renegotiate the 
relationship to a more equitable and satisfying equilibrium.
Patients in a 
role transition
 find themselves in the midst of a life change that 
feels overwhelming. This could be a change in a relationship (marriage, di-
vorce), a job change, a geographical move, the birth of a child, the diagnosis of 
a serious illness, or any other disturbing life event. This has clear application 
to PTSD, a disorder defined by a life event. Treating a role transition resembles 
treating complicated grief, although here no one has died. The framework of 
a “role transition” helps the patient recognize the connection between the life 
change and mood change; the therapist encourages the patient by affirming 
that, as he or she accommodates to the change, things should settle down.
Because, as with grief, patients tend to see the past as having been stable and 
happier, and the present as miserable and hopeless, the therapist explores how 
the patient feels about the loss of the old role (“What was good about being 
married?”) while encouraging mourning for what has been lost. At the same 
time, the therapist helps the patient see limitations of the past role and weigh 
both negative and positive aspects of the new role. Even difficult new roles gen-
erally have some positive aspects.
The IPT focal problem area of last resort, “
interpersonal deficits
” means 
that the patient’s history lacks the central life event on which IPT usually fo-
cuses. No one has died; there is no role dispute or role transition. Instead, the 
therapist must focus on the patient’s social isolation, which is often chronic, 
and point out that this isolation or social difficulty is contributing to their de-
pressed mood. The goal is to cautiously build social skills so that the patient 

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I P T   F O R   P T S D
can gain social comfort in interpersonal interactions and social supports in his 
or her environment.