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Phase 3.
The final few sessions of acute treatment constitute the
termination phase
. Its multiple goals include consolidating the patient’s
gains during treatment, dealing with the separation of ending, and
looking ahead to the future. If the patient has improved, the IPT
therapist asks, “Why are you feeling better?” The answer generally leads
to the understanding that the patient has improved because of his or her
own efforts. Patients tend to credit their therapists for improvement, but
it’s important to give patients who have been feeling helpless and passive
a sense of their own agency and independence, particularly when they
are leaving treatment. The structure of IPT generally makes it clear that
the therapist may have functioned as a helpful coach, but that the patient
has done the hard work: having quelled a role dispute, for example.
This is an opportunity to identify and reinforce interpersonal skills the
patient has developed during the treatment.
If the patient remains symptomatic but IPT has clearly reduced symptoms,
it may be appropriate to conclude acute treatment but to make a new treatment
contract for continuation of IPT. Similarly, if the patient has remitted but faces
a high risk of relapse, maintenance IPT— perhaps at a lesser frequency, such
as once fortnightly or once a month— has been shown to have a protective
effect (Frank et al., 1990; Frank et al., 2007). If the patient has not significantly
improved, termination becomes an opportunity to review whatever gains the
patient has made— often the patient has achieved some interpersonal progress,
but symptoms have not responded— and to emphasize that the therapy, not the
patient, has failed. This medical model echoes a pharmacotherapy trial: if one
treatment doesn’t work, that’s disappointing, but thankfully there are alterna-
tive treatments available. The crucial issue is that the patient not blame him- or
herself and feel too discouraged to continue in another, potentially more help-
ful treatment (Markowitz & Milrod, 2015).
Separation generally evokes sadness, but the patient may have various feel-
ings about stopping therapy, including anxiety about having to function on his
or her own, relief at no longer having to attend sessions, etc. The IPT approach
does not focus on transference, but rather on the patient’s emotional responses
to ending what has hopefully been a helpful relationship.
Termination is also a moment to anticipate issues in the patient’s future.
What aspects of the interpersonal focus remain unresolved, and how might
the patient want to address them? What problems are likely to arise over time?
4
Adapting IPT for PTSD
A difference, to be a difference, must make a difference.
— Gertrude Stein
This manual adapted Interpersonal Psychotherapy for use by therapists in a
14- week treatment study of chronic posttraumatic stress disorder. It is in-
tended as a guideline for treatment, as an extension of the basic IPT manual
(Weissman et al., 2007), and as an adjunct to IPT supervision.
Although IPT
for PTSD does involve some adaptations from standard IPT for major depres-
sive disorder, if you have previously used IPT, the basic approach is the same
and should feel familiar to you.
This was certainly the experience of thera-
pists in our randomized trial (Markowitz et al., 2015), who had previously
treated major depression. When they began the study in 2008, we told the
therapists that an open trial of IPT for PTSD had yielded very encouraging
results (Bleiberg & Markowitz, 2005), as had a randomized trial of group IPT
for PTSD (Krupnick et al., 2008).
A key issue in the 2015 randomized trial was to ensure that IPT therapists
not conduct an exposure- based treatment. That is, IPT could not involve en-
couraging patients to face and habituate to fearful reminders of traumatic
events. IPT is not inherently exposure- based, but we wanted it to be clear that
no exposure was taking place. IPT supervision and adherence ratings of IPT
tapes helped guarantee the purity of psychotherapeutic approaches. Indeed,
for IPT we added an adherence item, asking raters to judge (see Figure 4. 1).
Exposure therapies (exemplified by Prolonged Exposure) and IPT start from
the same premise that the patient has experienced a traumatic event— trauma
being the necessary precursor to the diagnosis of PTSD. But whereas exposure-
based therapies then focus on reconstructing jumbled memories of the trauma,
creating a hierarchy of feared trauma reminders, and sequentially exposing the
48
I P T F O R P T S D
patient to these until he or she habituates to the stimulus and stops feeling so
frightened, IPT takes a very different approach. Table 4. 1 summarizes some
differences between IPT for PTSD and exposure- based treatments for PTSD.
The elements of IPT remain unchanged: there is an initial, a middle,
and a termination phase. The therapist provides the patient with a medical
model:
PTSD is a debilitating but treatable disorder that is not the patient’s
fault.
The treatment focus remains on emotions and interpersonal circum-
stances. We adapted IPT to a degree, however, to address the specific issues
that patients with chronic PTSD face.
1.
Affective reattunement.
One clinical difference between patients who
present with major depression and those with chronic PTSD is that
To what degree did the therapist encourage the patient to expose him/herself to feared
trauma reminders?
1
2
3
4
5
6
7
Not at all
Some
Considerably
Extensively
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