Interpersonal Psychotherapy for Posttraumatic Stress Disorder

something
: a little hurt, a little angry at Mark. In the third session, the therapist 
framed the problem as a role dispute: Victor was entitled to decent treatment 
from Mark (and everyone else) and wasn’t getting it.
Therapist: As we’ve determined, you are suffering from PTSD and 
depression, treatable conditions that aren’t your fault. You have a 
good chance of getting better in the course of these 14 sessions; 
this is only our third. As I understand it, you’re in a very painful 
relationship with Mark, and to some degree also with other people 
around you. These are one- sided relationships in which they’re taking 
advantage of you, being mean to you, not treating you well. We call 
this kind of painful relationship a 
role dispute.
 If we can figure out a 
way for you to renegotiate the relationship so that it’s fairer and goes 
better, not only will your situation at work be better— feel safer and 
more secure— but your PTSD and depression symptoms are likely to 
improve, too: you’ll have made your life better, and you’ll feel better, 
too. I think there’s a good chance that you can accomplish this in the 
coming weeks. Does that make sense to you?
Victor: It makes some sense, but I doubt I can do it.
Therapist: That kind of pessimism is the depression talking. I think 
your odds are pretty good. Worth a try?
Victor: Yes. Can’t hurt.

---

Role Disputes 
121
Recognizing Victor’s history of repeated abuse and revictimization, the 
therapist made a point of encouraging Victor to bring up any discomfort 
he might have in the therapy sessions (“If there’s anything I do that both-
ers you, please let me know; it isn’t intentional”)— the therapist wouldn’t be 
insulted, would in fact welcome his raising his feelings in the session. Victor 
relaxed a little bit after this encouragement, but he never raised objections 
to the treatment.
The therapist pointed out that one key way to know that he was being 
mistreated was through his feelings, the feelings that were starting to break 
through the numbness Victor had chronically reported. Anger and hurt were 
reactions to mistreatment. As Victor began to raise such feelings, the ther-
apist spent several sessions normalizing them:  “They’re not ‘bad’ feelings; 
they’re appropriate responses to the bad behavior of other people!” But Victor 
had so long been so passive, had so little experience in confrontation, that al-
though he acknowledged the feelings, he remained hesitant to act on them. 
The therapist raised the concept of 
transgression
 (see Chapter 6) in an attempt 
to mobilize him.
Therapist: There are some written or unwritten laws of society that 
everyone knows: what’s fair is fair, and what is unfair is unfair. 
There are some behaviors that everyone would agree are bad— that if 
someone else does it to you, you’re right to be angry, and at the very 
least entitled to an apology. The way Mark treats you— the insults, 
the disrespect— that’s just not the way any human being should treat 
another. You’re standing on solid ground if you object to that.
Victor: That’s an idea. An apology.
They role- played how Victor might handle this.
Victor: [hesitantly] “Mark, you have to stop insulting me all the time. 
You have to stop dumping stuff on my desk. No one should treat 
another person that way. You owe me an apology.”
Therapist: How did that feel?
Victor: I don’t know. Artificial. Pretty wimpy.
Therapist: Did you say what you wanted to say?
Victor: Yeah, the ideas were okay, it’s the way it came out.
Therapist: What sounded wrong?
Victor: It just didn’t sound forceful— he’d steamroll right over me if 
I said something like that.
Therapist: How would he do that?

---

122 
I P T   F O R   P T S D
Victor: He’d say, “Fuck you— you can’t talk to me like that, you 
pussy!”
Therapist: That’s ugly. But if he did that, how could you respond?
Victor: Respond? 
…
 I guess I could say, “That’s the kind of talk no 
one should use— you owe me an apology.” But it still sounds flat.
Therapist: So the content is good, but you’re unhappy with the 
delivery?
Victor: Yeah.
Therapist: Well, let’s try it again. How would you like to say it?
Victor: Stronger. Like [louder]— “Don’t talk to me like that, you 
bully!”
Therapist: How was that?
Victor: A little better.
Therapist: How do you think he’d respond?
Victor: Well, I guess he might punch me, but really— I think he’d be 
shocked that I said anything
…
. Or maybe, “How dare you! Never 
talk to me like that again, you big bully, or I’m reporting you. And 
you owe me an apology.”
The therapist commented that “bully” was a perfect description of Mark. 
They continued to role play over the next two sessions. (“And stop dumping 
your work on me— do it yourself!”) Victor came to session 8 looking much 
brighter, and reporting that he had confronted another co- worker, Jim, with 
success. Jim said he was sorry, that he hadn’t meant to bother him. This em-
boldened him to take on Mark, and that, too, went surprisingly well. Mark 
hadn’t exactly apologized, but he had looked down, abashed. After one later 
short- lived attempt at braggadocio, Mark had left him alone. He was no longer 
putting junk or work on Victor’s desk. Victor felt relieved, better about him-
self. Over the next weeks he reported that he actually felt good rather than 
fearful going to work. It was beginning to feel like a somewhat safer place. He 
felt better able to defend himself. Some people were even acting a little nice 
toward him.
With a new appreciation for the benefits of recognizing and expressing 
anger, Victor raised a new issue in session 10. His troubles had started with his 
molestation by his priest. He had been reading in the paper about the Church 
scandals. Maybe he deserved an apology from the Church? The therapist lis-
tened and asked him how he felt.
Victor: I think he treated me horribly, took advantage of his holy office 
to molest me and silence me. I’m still hurt, embarrassed, and angry. 
I think he 
does
 owe me an apology.

---

Role Disputes 
123
Therapist: I think you should trust your feelings.
Victor went to his parish and asked how to proceed. He also asked at 
MaleSurvivor, an organization familiar with this issue, which provided sup-
port, encouragement, and information. He lodged a formal complaint, which 
felt good. He also raised the topic of having closer, more open relations with 
his family, and role- played talking to one of his brothers. He did not, however, 
pursue that further.
Work continued to go well. Mark made no more trouble, and indeed 
Victor’s standing up to him seemed to have led to a comeuppance: other work-
ers showed their disapproval of Mark. It felt a lot safer. A co- worker asked 
Victor if he’d like to have lunch. He was nervous, but agreed. It went a little 
awkwardly, but pretty well. Victor began to feel friendly toward a few of his 
co- workers and, as he emerged from his defensive stance, they responded pos-
itively to him.
As treatment approached termination, Victor and his therapist discussed 
Victor’s social life. The therapist wondered aloud: If he had made a safe space 
for himself at work, if he could use anger to react to disagreements and rene-
gotiate relationships, might it be safe for Victor to risk social relationships? 
The rules of social functioning are vaguer than the job descriptions at work, 
but Victor seemed to have grasped the principle. Victor agreed that this was a 
goal for the future. By the time therapy ended, at 14 sessions, he was increas-
ingly comfortable with work acquaintances but had not yet risked a romantic 
relationship. His CAPS score had decreased to 24, and he did not meet formal 
criteria for PTSD; his Ham- D score had fallen to 8, consistent with remission. 
There was no hint of borderline personality disorder symptoms. He had not 
cut himself. He felt life was worth living and had some hope for the future.
Victor did not call in at six months, but at the end of the year, the therapist 
received a long letter from him. Victor reported that all was well: he was feel-
ing good, safer, more sure of himself, if still a little anxious— but not numb, 
not depressed, nothing like before. He had asked for and received a promo-
tion at work, where he was getting along with other people. Mark had been 
transferred to another department, to general relief. Victor had spoken to his 
mother and one brother about his life, including raising the story of the priest. 
This time they had said they believed him, which had been very gratifying. He 
had received no word, no satisfaction from the Church. He had dated a little, 
but felt he still needed to work on that, and asked for a referral for further 
psychotherapy.
Patients with early childhood and repeated traumatizations often present 
like this: beaten down, passive, emotionally disconnected. There is a huge po-
tential for growth in interpersonal functioning under such circumstances if 

---

124 
I P T   F O R   P T S D
the therapist can engage the patient’s interest in his or her emotional life and 
its interpersonal meaning. Victor, who had never previously been in therapy, 
was in many ways a model patient: motivated, despite his anxious hesitancy; 
determined, despite the chronicity of his symptoms and the impoverishment 
of his environment. Perhaps feeling the pressure of the 14- week time limit, he 
made the most of his brief treatment.
Although the pattern of trauma Victor had suffered was evident, the treat-
ment did not focus on recounting or reliving it, or on facing reminders of 
the trauma. IPT focused squarely on interpersonal functioning. If in the end 
Victor tried to confront the priest who had molested him, it was on his own 
initiative— not something the therapist had raised— and followed naturally 
from his having first confronted Mark at work. Note, too, that the therapist 
could have framed this case as either a role dispute or role transition, where 
the transition would have involved recovery from years of abuse. The role dis-
pute format seemed preferable, given the current conflict Victor was enduring 
at work.
Victor was a research study patient, and treatment had to end at 14 weeks. 
He had nearly remitted at this point (technically, a CAPS score of 20 consti-
tutes PTSD remission; but he no longer met 
DSM- IV
 criteria for either PTSD 
or a mood disorder). Nonetheless, he was just finding a new equilibrium, just 
taking new positive steps in his life. Had this not been a research protocol, con-
tinuation or maintenance IPT might have been helpful. When Victor wrote a 
year later, the therapist made that referral.

---

10
IPT  for PTSD— Termination  
Phase and Maintenance
TERMINATION
The therapist should announce termination by session 10 or 11 of 14, although 
with fragile patients, it is often helpful to raise the issue earlier. Because pa-
tients know from the start that treatment is time- limited, they generally  
tolerate the ending of IPT well. If they are better, they may well not want to 
continue treatment. If IPT has not helped them in 14 weeks, it may realistically 
be time to switch to another treatment that might help the patient more.
The tasks of termination include:
 •  Consolidating the patient’s gains in therapy, thereby
 •  Increasing a sense of competence once therapy ends
 •  Emotionally acknowledging the end of treatment
 •  Deciding on next steps