Interpersonal Psychotherapy for Posttraumatic Stress Disorder

validating 
the feelings
 so as to encourage their expression, thereby clarifying 
a future interchange and giving the patient a sense of mastery and 
control over what happens.
 4. 
Tolerating affect.
 The above process allows what IPT calls 
communica-
tion analysis
. It should make clear what has happened in the reported 
interaction and how the patient has felt and behaved in it. It should 
also allow you to help normalize the patient’s emotional responses to 
interpersonal encounters. This affective attunement plays an impor-
tant role in IPT generally, but a particularly large role in IPT for PTSD, 
where patients are likely to describe numbness or no feeling, and to 
associate strong feelings with danger. Again, you can model for the 
patient in sessions that 
strong emotions, while uncomfortable, are not 

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Middle Phase 
73
dangerous
, and will pass if the patient just sits with them. Moreover, 
feelings are crucial emotional guideposts about what is happening 
in relationships, whom patients can trust or cannot trust. So while 
you may feel tempted— especially if a strong affect has arisen in the 
room— to move on to exploring options, don’t rush.
Let the patient sit with the feeling long enough to recognize that it’s mean-
ingful, not toxic. (A behaviorist might argue that this is a form of exposure 
and habituation, and it is; but such exposure is far from the graded, systematic 
hierarchy of exposure exercises that constitute most behavioral therapies for 
PTSD.) An emotional session is generally a good session, even if it can feel ex-
hausting. And it builds the reflective emotional capacity of the patient.
Your own emotional responses to the interpersonal encounters the patient 
describes should provide you with a template for responses. If you feel angry, 
or sad, or anxious on the patient’s behalf— if that’s how you would feel in that 
situation— that probably tells you something about a normative emotional 
response.
 5. 
Options.
 Having established where things might have gone right or 
wrong in the encounter the patient is reporting, you as the thera-
pist can support the patient’s having risked the encounter in the first 
place, and reinforce any skills the patient has used adaptively in the 
encounter.
“Brave of you to try. Are there parts of what happened that you’re 
happy with?”
If the interchange has ended badly, you can sympathetically and supportively 
help the patient explore why:
“Good that you tried. How did that feel? 
…
 I understand your disappoint-
ment about the way it ended. Where do you think things went wrong?”
Having normalized the patient’s affective responses to the situation— having 
helped the patient recognize that a sad feeling reflected separation from a loved 
one, an angry feeling reflected perceived mistreatment— you can then explore 
other options
 the patient might use in the given situation:
“What else could you try if that situation came up again?”
Patients may insist that they have no options, but that’s almost never true. 
Even if options are few and difficult, they exist. Encourage the patient to come 

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74 
I P T   F O R   P T S D
up with options rather than offering suggestions yourself: this will help the 
patient feel more competent. New options almost always exist, even if they’re 
hard for a benumbed, anxious, and helpless- feeling patient to locate. Helpful 
options start with how the patient was feeling— say, angry— and your valida-
tion of anger as an appropriate social signal under the circumstances.
“So 
how
 were you feeling at that point? 
…
 And is it reasonable for you to 
have felt that way [given her behavior]?”
Some patients may need repeated, gentle (not overly didactic) psychoeduca-
tional reinforcement that it’s okay to be angry if someone has offended you, 
and that the only way the other person will know they’ve offended you— and 
stop behaving that way— is if you tell them.
Feasible options often involve