Interpersonal Psychotherapy for Posttraumatic Stress Disorder

Our Open Trial.
 We have conducted two studies of individual IPT for PTSD. 
The first was an open trial— all patients received IPT— at Cornell University 
Medical College in New York, which we had begun even before the September 11,  
2001, attack made PTSD huge news in New York City. Our reasoning in adapt-
ing IPT for PTSD was this.
  1.  Interpersonal Psychotherapy links patients’ syndromes (for example, 
major depression) to important life events that either trigger or result 
from the psychiatric disorder. Psychiatric disorders do not occur in a 
vacuum, but in an interpersonal context. In extending IPT from mood 
and eating disorders to anxiety disorders, PTSD seemed the obvious 
place to start, as it is a disorder defined by a life event.
  2.  Because various exposure- based treatments for PTSD existed, we felt 
IPT should take a different approach. Never exposure- focused, IPT 
would not reconstruct traumatic events with patients, but would 
rather address 
the interpersonal sequelae of having been traumatized.
 
Rather than reconditioning patients not to fear reminders of their 
trauma, IPT would help patients regain social supports and figure out 
whom they could trust and not trust in their social world.
 

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8 
I P T   F O R   P T S D
  3.  We noticed that trauma shatters patients’ sense of safety about their 
environment and about people in their environment. Individuals with 
PTSD suffer from affective distancing or numbing, and withdraw so-
cially. Unable to trust their feelings, they cannot “read” or trust their 
environment. Numbed, they avoid or try to ignore painful negative 
affects (anger, sadness, anxiety) that in fact serve as important signals 
about interpersonal encounters. Without such input, patients were 
“flying blind” and likely to be revictimized, not knowing whom to 
trust and whom to avoid. Hence we decided to focus the initial stage of 
IPT treatment on 
affective attunement.
 We asked patients repeatedly 
how they were feeling, what the name of the feeling was (“I’m upset,” 
for example, is non- specific), whether it was a reasonable reaction to 
the interpersonal encounter, and what it might tell them about that 
encounter. In discussing current daily interactions— not past trau-
matic events— we tried to help patients gain an emotional vocabulary 
for their interactions, to see negative emotions not as dangerous but 
as useful interpersonal signposts they could use to decode confusing 
situations.
With Kathryn Bleiberg at Cornell, I wrote the first version of the treatment 
manual that is the basis for this book. We somewhat arbitrarily set the length 
of treatment at 14 weekly 50- minute sessions. As no one had tested IPT for 
PTSD, we had no idea how long treatment ought to last.
Our initial open study (Bleiberg & Markowitz, 2005)  treated 14 patients 
with chronic PTSD. Therapists used much of the first half of treatment to re-
build emotional attunement in benumbed patients— this symptom is not typ-
ical of depression, but it is a hallmark of chronic PTSD. Then therapists applied 
standard IPT maneuvers to patients’ difficulties with trust and expressing 
emotions in daily relationships. Therapists avoided encouraging exposure 
to trauma reminders. Patients with varied, but predominantly interpersonal 
rather than impersonal, traumas received 14 weekly IPT sessions. All but one 
patient completed treatment.
At the end of treatment, 12 of 14 patients no longer met diagnostic crite-
ria for PTSD. CAPS (Blake et al., 1995; Weathers et al., 2001) scores fell from  
67 (SD = 19) to 25 (SD = 17), a large within- group effect (d = 1.8), with im-
provement across PTSD symptom clusters. This drop in the CAPS score took 
patients from severe PTSD to near- remission. Depressive symptoms, anger re-
actions, and social functioning improved. As patients became more comfort-
able with their emotions and handling daily interpersonal encounters, they 
exposed themselves to traumatic fear reminders without therapist encourage-
ment— a change necessary for PTSD remission. (See Table 1.2.)

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Is Exposure Therapy Necessary to Treat PTSD? 
9
Patients reported general interpersonal improvement on the Social 
Adjustment Scale (Weissman & Bothwell, 1976) and other interpersonal 
measures. Ten completed the Interpersonal Psychotherapy Outcome Scale 
(IPOS; Markowitz et  al., 2006), a self- report measure on which patients 
score change in the interpersonal problem area which IPT focused on 
during the treatment interval. On the IPOS, 1 = significant worsening in 
the area, 2 = mild worsening, 3 = no change, 4 = mild improvement, and 
5  =  significant improvement. All subjects reported some positive inter-
personal change (minimum score = 4), and mean improvement was 4.77 
(SD = 0.34) out of a possible five. IPOS scores correlated with CAPS im-
provement:  that is, how much patients improved in resolving their in-
terpersonal difficulties correlated with reduction in PTSD symptoms 
(Markowitz et al., 2006).
Ten patients completed the Inventory of Interpersonal Problems (Horowitz 
et al., 1988), a measure of interpersonal difficulties, and showed significant 
improvement in total score (ES = 1.15; Wilcoxon Signed Ranks Test, 
p
 = 0.005) 
and on all subscales, particularly the Cold/ Distant (ES  =  1.39, p  =  0.008) 
and Self- Sacrificing (ES = 1.38, 
p
 = 0.009) circumplex subscales. Compared 
Table  1. 2.
  Cornell Trial: Scores at Baseline and After 14 Weeks of IPT- PTSD