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People who de-
velop PTSD suffer from interpersonal problems.
Among the key consequences
of PTSD are:
a. Affective detachment— emotional distancing from people and daily life
b. Mistrust of the environment— particularly when the trauma has been
an interpersonal one, inflicted by someone else; and
c. Interpersonal hypervigilance.
Adapting IPT for PTSD
51
The patient withdraws from activities (
DSM-5
PTSD symptom C.2), feels
estranged from others (symptom D.6), experiences a constricted affect
(symptom D.7), often with outbursts of irritability (symptom E.1), and not
only a physiological but an interpersonal hypervigilance (symptom E.3) and
mistrust (symptom D.2) (American Psychiatric Association, 2013). Note that
whereas exposure- based treatments tend to address PTSD B and C criterion
phenomena, IPT focuses on the more interpersonal items. The DSM emphasis
on cognitive and behavioral symptoms to define PTSD may to some degree re-
flect the dominance of Cognitive Behavioral Therapy (CBT) as a treatment for
the disorder. Interpersonal aspects may to some degree have been underplayed.
The IPT therapist takes the position that it’s unfortunate enough that the
patient has suffered the precipitating trauma; the patient needn’t be doubly
punished or cheated by losing his or her social life and sense of place in the
world as well. That’s literally “
adding insult to injury
.” Treatment therefore rep-
resents a reparative
role transition
from a traumatized to a healthy state, in
which the patient reclaims his or her former level of functioning. (This is the
concept of an
iatrogenic role transition,
in which the IPT therapist frames the
therapy itself as a brief period of recovery from a chronic psychiatric disorder
[Markowitz, 1998; Lipsitz et al., 1999].) This role transition can be a particu-
larly germane focus if the patient’s traumatic symptoms are longstanding and
related to a temporally distant trauma, analogous to patients treated with dys-
thymic disorder and social phobia in other IPT studies.
Again: although the therapist must acknowledge the patient’s trauma as a
serious and naturally upsetting event, and must review the trauma during the
initial history- taking, the
subsequent focus of treatment is not on the traumatic
event, but on its reverberations in numbed emotions, shattered social relation-
ships, and loss of formerly pleasurable activities and routines
.
How IPT works is unknown. It is plausible that PTSD symptoms improve
in IPT because IPT- PTSD encourages patients to tolerate affect, to risk po-
tentially emotional encounters with others, and to build social supports. IPT
helps patients identify their emotions as interpersonal signals and use them
to respond appropriately. This leads to interpersonal “success experiences”
(Frank, 1971), reassuring patients of environmental mastery. Indeed, symp-
tomatic improvements in PTSD patients from our pilot study correlated with
the extent to which patients succeeded in making interpersonal changes in
their focal problem area (e.g., role transition) (Markowitz et al., 2006). We
surmise from clinical experience that improved mastery in these everyday
experiences, together with more secure, “safer” interpersonal attachments, en-
courages patients to risk confronting traumatic reminders. This is captured
scientifically as a reduction in avoidance symptoms. The IPT medical model
52
I P T F O R P T S D
also normalizes trauma reactions for patients, much as the psychoeducational
phase of CBT normalizes symptoms, helping reduce feelings of shame. Even if
the mechanism of IPT ultimately proved linked to
in vivo
exposure, yet man-
aged to retain and successfully treat exposure- averse patients, it would finesse
an important clinical problem. For patients reluctant to confront traumatic
reminders, an interpersonal model could be an effective alternative for en-
gaging them in treatment.
Our modification of IPT for PTSD thus focuses on
how trauma has com-
promised patients’ current interpersonal perspective and social functioning
. We
postulate that
trauma impairs the individual’s ability to use the social environ-
ment to process environmental trauma
. Trauma shatters the individual’s sense
of environmental safety and poisons his or her trust in interpersonal relation-
ships. Hence the individual with PTSD withdraws from, or distances him- or
herself within, relationships, and restricts social activities. This withdrawal
prevents the individual from obtaining needed social support. Experiencing
the environment and relationships as “dangerous” triggers maladaptive social
functioning that helps perpetuate PTSD, whose symptoms in turn reinforce
social detachment and dysfunction. IPT may counter the internal perception
of helplessness, shame, and interpersonal danger in PTSD with perceived in-
terpersonal understanding and social competence.
The focus of IPT on current relationships shifts the patient’s attention
from inner preoccupation with past trauma to coping with the immediate
interpersonal outer world. Treatment addresses not potentially frightening
re- exposure to traumatic memories or reminders, but quotidian encounters
with friends, family, and coworkers. By helping patients test their interper-
sonal environments and recognize that they are safer than their traumatic
expectations allow, this approach may help PTSD patients mobilize social
supports (Brewin et al., 2000, Ozer et al., 2003) and restore interpersonal
functioning, yielding improved interpersonal comfort and generalized
symptomatic relief. Mobilizing and increasing available social supports pro-
vides a task for the patient while meeting an important clinical need. PTSD
patients have withdrawn from available social supports, compounding
their isolation and feelings of mistrust. Re- engaging with social supports,
or finding new ones, may relieve PTSD symptoms, reintegrate the patient
into the social environment, and build interpersonal skills to improve social
function.
The process of symptom improvement obviously includes reversal of avoid-
ance patterns, and may to a degree resemble the trajectory of exposure- based
therapies. Although IPT- PTSD and exposure therapy for PTSD differ in struc-
ture and technique, their primary difference is in therapeutic focus: interper-
sonal problems vs. behavioral avoidance. Yet for IPT- PTSD to have efficacy,
Adapting IPT for PTSD
53
it must ultimately reverse behavioral avoidance despite eschewing elaborate,
systematic in vivo hierarchies as primary treatment emphasis.
3.
Mobilizing social supports
. IPT therapists always look for potential
social supports in their patients’ environments and encourage patients
to find and use them. This may have particular salience for benumbed,
socially withdrawn patients with PTSD (Brewin et al., 2000, Ozer
et al., 2003, Markowitz et al., 2009).
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