Interpersonal Psychotherapy for Posttraumatic Stress Disorder

elicit
 the patient’s feelings in such situations, 
validate
 and 
nor-
malize
 them, 
explore options for expressing them
 (verbally), and 
role play
 them. 
Taking this one step at a time is important; don’t rush to explore options until the 
patient has tolerated and recognized the feelings. As a therapist, you don’t want 
to communicate the idea that feelings need to be avoided, that you or the patient 
should rapidly move on when a strong affect is uncovered. Better to sit with feelings, 
to tolerate (demonstrating that they are not dangerous) and to understand them.
One concept that is sometimes helpful is the idea of a 
transgression
 
(Weissman et al., 2007). Certain behaviors break social codes, written or un-
written societal laws. Under such circumstances, 
anyone
 who has been trans-
gressed against has a right to feel angry; anyone is entitled to an apology (if not 
greater recompense). Examples of transgressions include rudeness, betrayal, 
lying, violence, and so forth. The concept of a transgression— of a universally 
accepted violation— may help cautious, passive patients to feel that social law 
supports them. This may be an important reframing in encouraging them to 
confront transgressors, renegotiating a maladaptive relationship.

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Middle Phase 
71
STRUCTURE OF SESSIONS
 1. 
Opening gambit.
 Each session after the initial one begins with the 
question: “
How have things been since we last met?
” This elicits an in-
terval history and focuses the patient on recent life events and associ-
ated affects. Exploring these helps patients connect feelings with life 
functioning. If the patient answers the question with an event from 
the interval between sessions, the therapist then asks how this affected 
the patient’s feelings and symptoms. Alternatively, if the patient has 
answered the initial question with a mood or symptom change, the 
therapist asks about events. Thus, after two opening questions, the 
therapist and patient have identified an affectively charged recent 
event to discuss. This is an excellent substrate for good psychotherapy, 
and it is the substance of IPT.
 2. 
What happened?
 The next step is to explore what happened. Where did 
things go right or wrong? What did the patient want to happen in that 
situation? How did the patient feel? When patients report success in an 
interpersonal encounter, the therapist provides 
support
 and 
reinforce-
ment
. (“Great job! 
…
 How did you feel after you did that?”) If the patient 
has suffered a setback, the therapist offers sympathy; therapist and pa-
tient then explore how current PTSD symptoms interfered with the en-
counters (and how these encounters in turn perpetuate such symptoms).
In reconstructing what is often a minor interpersonal encounter— albeit one 
with an emotional impact on the patient’s mood, suffering, and confidence— 
try to help the patient organize what has happened, essentially reconstructing 
a transcript of the experience.
“What did you say? 
…
 What did [s] he say? 
…
 Then how did you feel? 
…
 
Then what did you say?”
Repeat this interrogatory triad (what IPT technically calls 
communication a-
nalysis
) as often as needed to reconstruct the encounter. The information you 
gather can help both your and the patient’s understanding on several levels:
  1.  It should give you a sense of how the patient interacts moment to 
moment in an interpersonal exchange with a potentially important 
family member, friend, or co- worker. Over time, these vignettes from 
the patient’s life will add up to a much more detailed and accurate pic-
ture of the patient’s interpersonal behavior than any generalizations 
the patient can provide.
 

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72 
I P T   F O R   P T S D
  2.  Just recognizing the feelings that come up may be difficult for patients 
at first, due to the numbness and emotional avoidance of PTSD. This 
experience of recounting interpersonal interactions thus provides a 
crucial experience in affective attunement.
“What did you feel when he said that? 
…
 Upset? 
…
 What kind of 
upset? What do you call that feeling?”
Gradually the patient may be able to distinguish among uncomfortable neg-
ative affects such as anger, sadness, and anxiety, all of which can tell you and 
the patient different things about what is happening in the interpersonal en-
counter the patient is describing. This builds an important emotional vocabu-
lary, a considerable accomplishment and a necessity for coping in the patient’s 
future interpersonal life.
  3.  You can listen for dissonances and discrepancies between how the 
patient reports feeling in the encounter (“How did you feel?”) and 
what the patient then says (“Then what did you say?”) to the other 
person. For example, did the patient feel angry but say nothing? We 
might expect that pattern as a consequence of PTSD. Such beha-
vior often leaves patients anxiously uncomfortable, and anger may 
subsequently boil over in a different, trivial, or inappropriate set-
ting, which only leads the patient to conclude that his or her feel-
ings are out of control and need to be suppressed still more severely. 
Meanwhile, by not expressing feelings during the interchange you 
are examining, the patient is not informing the other person of what 
he or she wants or does not want, thereby perpetuating a role dis-
pute. Thus, pursuing how the patient feels in an encounter is im-
portant in its own right, but any disconnection between what the 
patient feels and says has additional import. IPT works on