Interpersonal Psychotherapy for Posttraumatic Stress Disorder

 Macbeth, IV, 3 (1606)
Grief— complicated bereavement— follows the death of a significant other, the 
loss of a key relationship in an individual’s life. The death of a close family 
member has long been known to rank among the most stressful of life events 
(Holmes & Rahe, 1967). Grief might become the focus of treatment if a pa-
tient developed PTSD after having witnessed the violent death or murder of a 
spouse, child, other family member, or close friend. In our randomized trial, 
six (16%) of 38 patients who began IPT focused on grief.
CASE E X AMPLE
Leonard, a 65- year- old married white businessman, presented in 2006 for 
treatment of PTSD that began following the World Trade Center attack of 
September 11, 2001. Living in Hoboken, New Jersey, almost with a view of the 
World Trade Center, Leonard knew that his eldest son Rob, 35, was working 
on the upper floors of the North Tower. Hearing the news, he ran out of his 
house and found a high vantage point from whence he helplessly watched the 
burning buildings while listening on a Walkman to news reports. Following 
the collapse of the Towers, he watched innumerable repetitions on television. 
Subsequently, even when he had stopped watching TV, scenes of the terrorist 
attack replayed in his mind, as did images of his lost son.
He developed agitation, anhedonia, insomnia, and distractibility. He 
stopped eating and lost 45 pounds over several years. He withdrew from 
 
 
 

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others, stopped leaving the house, and sat alone in his room. Although he 
had three other grown children, who with his wife apparently did their best 
to comfort him, he felt he had lost his golden child and life no longer had 
meaning. He wished that he could die himself, that he had died in place of his 
son, that he had died before he ever saw such a day. His wife Rose arranged 
for him to come to treatment, which he approached reluctantly and hope-
lessly. On presentation in mid- 2006, he met 
DSM- IV
 criteria for both PTSD 
and major depression, with a CAPS score of 68 (severe) and Ham- D score of 
30 (severe). Leonard followed his wife and eldest daughter into the office with 
downcast eyes.
Leonard was a tall, graying, formerly athletic but now too thin white man, 
appearing older than his stated age, showing several days’ growth of beard. 
He was adequately groomed, casually dressed in jeans and a plaid work shirt. 
His movements were mildly agitated, his speech soft and restricted but fluent, 
and he looked at the floor more than at the therapist. His mood was anxious 
and depressed, with a constricted, sometimes detached affect. Thinking was 
marked by ruminations about his cursed life and lost son. There was no sug-
gestion of psychotic symptoms. He reported passive suicidal ideation without 
formal plans or intent. His intelligence appeared above average, his insight 
limited (he did not see himself as having a psychiatric condition, just that his 
world had ended). Sensorium was clear.
The therapist spoke briefly to the wife and daughter in Leonard’s presence 
but, gauging that the patient would be able to provide a history on his own, 
asked them to wait outside the office. He then introduced himself to Leonard:
Therapist: You look like you’ve been through something. How can 
I help you?
Leonard: I don’t think anyone can help me. My boy Rob was killed on 
9/ 11, and my life is over too.
Therapist: I’m so sorry to hear that. What a terrible thing! Tell me 
about Rob.
Leonard: He was great. He worked at [a financial firm] on the 104th 
floor of the North Tower. He was a superstar, had his whole life ahead 
of him
… 
. And now he’s dead.
This was trauma history enough. Although Leonard returned from time to 
time to ruminations about the World Trade Center, the rest of his treatment 
focused on grief, following the usual IPT approach. The therapist asked about 
what Leonard’s relationship with Rob had been like, starting with the positive; 
and what he missed about him. As treatment progressed, they also addressed 
rough points in the relationship, difficult times, things that hadn’t been so 

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wonderful. But the focus stayed on the relationship and the son, not on the 
trauma that had separated them.
The therapist expressed sympathy and began to take a history, starting with 
Leonard’s relationship with Rob and extending to the more general family 
situation. Len had been married for 38 years to Rose, and Rob had been his 
eldest of three sons and a daughter. Leonard loved his wife and other children, 
but said Rob had always been his favorite, the one he drilled to competitively 
“follow in my footsteps” as both a high school and college athlete and a sub-
sequent business success. Rob had been highly successful working in mergers 
and acquisitions, had married, had had two young children, and had lived in 
Manhattan, not far from his parents across the Hudson River. Leonard had 
frequently taken the ferry from Hoboken to visit this favored branch of the 
family. Now he never came to Manhattan at all.
An interpersonal inventory revealed that Leonard had always seen himself 
as a family man, the patriarch who barbecued on the Fourth of July. He had a 
few business colleagues he golfed with, but no one he confided in. Indeed, he 
had long prided himself on his self- sufficiency, on his capacity to control his 
feelings without needing to burden others.
Leonard denied prior trauma, mood or anxiety disorders, suicidality, and 
prior psychiatric treatment. He reported drinking two or three scotches a 
night, without evident adverse effects; he denied other drug use. His medical 
history was notable for smoking a pack of cigarettes daily for 40 years; no thy-
roid history or physical trauma. He had been taking a diuretic for hyperten-
sion for fifteen years.
Toward the end of the first session, the therapist pointed out that while al-
cohol might help Leonard fall asleep, it might also worsen his insomnia and 
risked compounding his depression. The therapist suggested cutting back, at 
least until Leonard got his symptoms under control.
Notice that, from the start of this opening session, the therapist focused 
history- taking on the patient’s relationship with the deceased son, not on the 
trauma 
per se
. This set the tone for IPT. At the end of the second session of a 
planned 14- week treatment, the therapist provided a formulation:
Therapist: You’ve given me a lot of helpful background; will you tell 
me whether I understand everything you’ve told me? You seem to 
have had a successful and happy life until you reached 60 and your 
son was killed. You have always been able to take care of yourself 
and control your life and protect your family; but who could have 
imagined an event like this? Losing a son, and maybe especially 
your favorite, eldest son, is one of the worst traumas anyone can 
undergo. Like many people who were directly affected by the 

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World Trade Center attack, you’ve developed posttraumatic stress 
disorder— as I told you, your score on the CAPS scale is in the severe 
range. PTSD is a treatable condition, and it’s not your fault. The same 
is true for the depression that often accompanies PTSD. It’s all a kind 
of