Interpersonal Psychotherapy for Posttraumatic Stress Disorder

Violence.
 The modal diagnostic target of IPT over the decades has been 
major depressive disorder, a diagnosis strongly associated with suicide but 
much less so with harm to others. One aspect of PTSD is that some patients 
may lose control of bottled- up, violent impulses and may pose risks to others 
(e.g., McFall et al., 1999; Fehon et al., 2005).
The therapeutic approach to forestalling harm to others follows that of harm 
to self. Risk of violence needs frequent monitoring as a worst outcome, just as 
suicidal risk does. The therapist should rule out or, if present, try to mitigate 
contributing factors such as alcohol and drug use, which can be disinhibiting 
(Wilkinson et al., 2015), and traumatic brain injury (Stein et al., 2015) or other 
medical factors that might magnify impulsivity. As with suicide, therapist and 
patient should work to fight any opportunity to give in to the symptoms: for 
example, impeding access to weapons.
Most PTSD patients are frightened by their own potential for violence and 
may respond well to therapist support (“Please call me if you’re worried you’re 
going to feel out of control”). As with suicidal risk, the therapist’s very gesture 
of offering availability often provides some reassurance to calm the patient, 
with the consequence of no calls and no dangerous outcomes. Therapist and 
patient should consider contingencies such as going to the emergency room 
if necessary (“What can you plan to do if you again start feeling like hurting 
her?”).
Some patients can appear menacing and indeed may pose some level of 
risk –  which is why they desperately need treatment. Your clinical judgment 
 

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Difficult Situations and Special Circumstances 
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is crucial in such situations in gauging how to proceed. A veteran who reports 
having weapons at home, or who may be carrying a knife for self- protection 
to your office, may not only feel very anxious him-  or herself, but may under-
standably cause you anxiety as well. The issue is best addressed directly. If the 
patient appears menacing, or if you feel menaced, you need to gauge the likeli-
hood of this being a true threat. You do not want to overreact to (and thereby 
magnify) the patient’s fears and risk, but you cannot ignore them. It is hard to 
conduct optimal therapy if you are worrying about your own safety.
Explore and identify the patient’s affect: “How are you feeling coming in 
here?” 
…
 “If you’re feeling fearful or unsafe, what options do we have to make 
these sessions more comfortable?” Acknowledging the emotion and treating 
it in measured, poised fashion is likely to calm both the patient and your-
self. When a menacing patient enters your office, you may want to discuss 
the seating arrangement: would the patient rather be nearest to the door, or 
in a position to keep an eye on the door? Would the patient perhaps prefer 
that you leave the door ajar? (You will not want to sit between the patient and 
the door.)
I have had sessions with patients who were carrying knives; I did not feel