Interpersonal Psychotherapy for Posttraumatic Stress Disorder

 The Open Door (1957)
Before we jump into Interpersonal Psychotherapy (IPT) as a treatment for 
posttraumatic stress disorder (PTSD), it’s helpful to have a clinical and a re-
search context. This chapter describes the state of accepted treatments for 
PTSD, the dominant theory and rationale supporting exposure therapy as a 
treatment, and the rationale and evidence for IPT as a treatment alternative.
E XPOSURE
A large body of randomized controlled clinical trials shows that exposure 
therapy, which exposes patients to reminders that evoke their traumas in order 
to extinguish excessive fears, benefits many patients with PTSD. Almost all 
empirically tested psychotherapies for PTSD have relied on exposure tech-
niques, dating back to Kardiner and Spiegel’s (1947) treatment of World War II  
veterans. Treatments like Prolonged Exposure (Foa et al., 1991), Cognitive 
Processing Therapy (Resick et al., 2008), Eye Movement Desensitization and 
Reprocessing (EMDR; Shapiro, 2001), and other treatments, mostly variants of 
Cognitive Behavioral Therapy (CBT), all rely on helping patients face triggers 
of frightening memories and experiences they avoid. (Cognitive Processing 
Therapy has also shown benefit sans its exposure component [Resick et al., 2008].)  
 
 
 

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I P T   F O R   P T S D
This exposure to trauma reminders, initially anxiety- provoking but taking 
place in a safe setting with a reassuring therapist, leads patients to recog-
nize that the reminders themselves are not inherently dangerous just because 
of their association with a traumatic event. Patients may long have avoided 
stimuli like physical settings (e.g., tall buildings, airplanes, and downtown 
Manhattan, for World Trade Center survivors), smells, colors, or objects asso-
ciated with the trauma. In treatment, they come to realize, through exposure, 
that this avoidance need not continue, and it need not interfere with their lives.
Exposure- based treatment is founded on very old behavioral principles: the 
more you fear something, the more you avoid it. Moreover, the more you 
avoid something, the more dangerous it seems, and the more you then fear 
it. This vicious cycle leads individuals to avoid a host of potential triggering 
stimuli, which avoidance constricts their lives. They live in fear of fear, avoid-
ing large areas of experience because, following a trauma, nothing really  
feels safe.
If a therapist can induce a patient to confront a reminder of a trauma and 
face it, fear initially rises but then subsides as the patient has a chance to re-
evaluate the trauma reminder (Foa & Kozak, 1986). This habituation lowers 
anxiety with each subsequent exposure, and may eventually extinguish the 
fear. Exposure therapists help patients construct a hierarchy of fears, rang-
ing from mild to severe, and start with the milder ones, building up to the 
seemingly most dangerous. In Prolonged Exposure therapy, therapists tape 
the 90- minute exposure sessions and send patients home to review the latest 
session tape every day for the remainder of the week. Thus therapy consists 
of 90- minute daily imaginal exposure. In addition, patients undergo 
in vivo
 
exposures; for example, returning to Ground Zero if the trauma involved the 
World Trade Center. Again, the principle is that, by facing reminders of your 
trauma, you can recognize that the triggering stimulus is not the trauma and 
can come to appreciate that fear reminders are not inherently dangerous. By 
the end of treatment, by repeatedly recounting the trauma and confronting 
its reminders, a patient ideally has constructed a seamless history of the trau-
matic incident(s), and has faced and become habituated to related fears.
Bolstering this behavioral fear- extinction paradigm, research studies have 
located a fear- extinction circuit in the brain. Individuals with PTSD have  
overactive amygdalas; neuroimaging studies have shown that behavioral treat-
ment strengthens “top- down” control by the prefrontal cortex, in effect subdu-
ing amygdalar activity (Rauch et al., 2006). Unlike the ego, id, and superego, 
then, the fear- behavior circuit has a definable neuroanatomical locus.
In recognition of this impressive clinical and physiological/ neuroanatomical 
research, treatment guidelines have unanimously endorsed exposure- based 
treatments as first- line interventions for PTSD. The American Psychiatric 

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Is Exposure Therapy Necessary to Treat PTSD? 
3
Association (APA) treatment guidelines for PTSD state: “The shared element 
[among efficacious treatments] of controlled exposure may be the critical in-
tervention” (APA, 2004). The United Kingdom National Institute for Health 
and Care Excellence (NICE) guidelines similarly endorse the approach: “All 
people with PTSD should be offered a course of trauma- focused psychological 
treatment (trauma- focused cognitive behavioural therapy [CBT] or eye move-
ment desensitisation and reprocessing [EMDR])” (NICE, 2005). The Institute 
of Medicine (IOM) recommended 
only
 exposure- based treatment, finding 
too little evidence to support pharmacotherapy of PTSD (IOM, 2008)— even 
though research indicates that treatment with serotonin reuptake inhibitors 
does benefit patients with PTSD (e.g., Brady et al., 2000; Marshall et al., 2001; 
Schneier et al., 2012).
Is exposure a necessary ingredient for treatment? Its necessity has in recent 
years become a near dogma in the field. Perhaps not since the heyday of psycho-
analysis has a theory so dominated a field as exposure- based theory does the 
psychotherapy of anxiety disorders today. (Research showing that Cognitive 
Processing Therapy minus its narrative exposure component does benefit pa-
tients with PTSD [Resick et al., 2008] has not changed the overall perspective 
of the field.) Exposure- based treatment does work, but— like all treatments for 
all conditions— it has limitations. Exposure therapy is difficult work that can 
be painful for patients and clinicians. Some patients (and therapists) refuse 
to do it, and the dropout rate is high: roughly 30% across studies (Hembree 
et al., 2003). Patients with high levels of dissociation may have poor outcomes, 
as their detachment may make it difficult for their exposure sessions to sink 
in (Lanius et al., 2010). Ninety- minute sessions may be difficult to incorpo-
rate into clinic practice. Despite an impressive rollout of exposure training for 
therapists in the Veterans Administration (VA) system, few therapists have 
actually been using these techniques, and dropout rates from such treatment 
have been high (Watts et al., 2014; Kehle- Forbes et al., 2016). So an empirically 
validated, non– exposure- based psychotherapy would be a valuable alternative 
for individuals suffering from PTSD.
ANOTHER THEORY
The fear- extinction theory makes sense for PTSD, a disorder based on a fright-
ening traumatic event and characterized by anxiety and avoidance. Yet that 
vantage is not the only possible perspective. Posttraumatic stress disorder also 
has numerous interpersonal features (Markowitz et al., 2009).
The 
DSM- IV
 (
Diagnostic and Statistical Manual
, 4
th
 edition) PTSD avoidance 
symptom cluster included descriptions of patients avoiding “conversations” 
 
 

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and “people” that evoke traumatic memories. Individuals may feel “detach[ed] 
or estrange[d]  from others,” show “restricted range of affect,” or have “irrita-
bility or outbursts of anger” in interpersonal contexts. “Diminished interest or