Interpersonal Psychotherapy for Posttraumatic Stress Disorder

Treatment Planning.
 Once having made the diagnosis, the clinician should 
present it to the patient. 
Giving the patient a diagnosis, and explaining that it is 
a treatable condition, and not the patient’s fault,
 is a standard maneuver of IPT 
therapists. It deserves to be used in any treatment plan. It helps patients know 
what afflicts them, and that it is treatable. Moreover, many patients suffer from 
guilt and self- blame as symptoms of their syndrome: this is true for both major 
depression and PTSD. Abused children, for example, frequently hear from 
their parents or other abusers that everything is their fault, and believe against 
all reason that their persecutors must be right. Combat soldiers frequently 
feel responsible for the witnessed death of a comrade (“survivor guilt”), even 
though the death was in no way their doing (Aakvaag et al., 2014). Hence, ex-
plaining the disorder and exculpating the patient frequently get treatment off 
to a good start.
The next question is the crucial matter of differential therapeutics: which 
treatment is likely to help the patient most? Several time- limited psychothera-
pies and several pharmacotherapies for PTSD have been empirically validated. 
 

---

34 
I P T   F O R   P T S D
Or treatment
s
: what about combining medication and psychotherapy (Schneier 
et al., 2012)? I suggest that therapists not be dogmatic. Many or most thera-
pists have a preferred treatment, which they employ most frequently and with 
which they feel most comfortable. Treatment, however, is supposed to follow 
informed consent, and informed consent should include a balanced discus-
sion of empirically proven available options, addressing their pros, cons, and 
empirical support. It helps patients to know that multiple treatment options 
exist, and that if one treatment does not help, another well may. Patient treat-
ment preference tends to matter (Markowitz et al., 2015a), and showing the 
patient that you value and respect the patient’s input is likely to enhance the 
therapeutic alliance (Cloitre et al., 2002, 2004), again starting treatment on 
a positive note. This may have particular value in working with patients suf-
fering from PTSD, who mistrust their environments and the people in them. 
Different treatments may also have particular advantages for particular pa-
tients, based on studies of moderating variables, such a comorbid depression 
(see Chapter 1).
Offering the patient a time- limited rather than an open- ended psycho-
therapy has several advantages. First, it is the time- limited psychotherapies 
that have received empirical validation (in part because their brevity makes 
research funding feasible). Thus you can tell the patient that there is evidence 
backing the treatment approach. Second, if the treatment does not help the 
patient, it has a reasonably brief course and a definable end, after which the 
patient can move on to an alternative treatment (Markowitz & Milrod, 2015). 
Not to define an end to treatment risks years of unhelpful if well- intended 
therapy.
Third, and perhaps most important, many patients who have PTSD may 
have lived with its symptoms for decades, if not their whole lives. They often 
take years to reach treatment: a median delay of 12 years, according to one 
study (Wang et al., 2005). If, when they do present for treatment, a therapist 
can offer them a proven (albeit not guaranteed) treatment that may relieve 
many of their symptoms in a matter of weeks, that paradoxical gambit of time- 
limited treatment for a chronic condition may provide a therapeutic shock. 
Patients may think or say, “You mean I don’t have to live like this?” They may 
remain skeptical about the treatment until they are better, but the idea that a 
condition that has lingered for years can be treated acutely carries therapeutic 
weight (Markowitz, 1998).
Readers of this book will most likely practice psychotherapy (or hopefully, 
psychotherapies) and, like most patients with mood and anxiety disorders, you 
may prefer psychotherapy to medication as a treatment (McHugh et al., 2013). 
Nonetheless, the medication option should not be ignored. Pharmacotherapy 
rarely induces remission in PTSD, but it can help greatly (Marshall et al., 2001).  

---

The Target Diagnosis 
35
As Schneier et al. showed in a small study, the serotonin reuptake inhibitor 
(SRI) paroxetine (Paxil) augmented the effects of Prolonged Exposure therapy, 
with combined treatment yielding better effects than Prolonged Exposure 
alone (Schneier et al., 2012). I tend to find sertraline (Zoloft) better tolerated, 
and there is a research literature showing that it, like paroxetine, reduces 
PTSD symptoms. Whatever gets the patient better is the ultimate means to the 
ultimate end of recovery.

---

3
A Pocket Guide to IPT
Man is a social animal.
— Baruch  Spinoza
BACKGROUND
Several manuals illustrate the use of interpersonal therapy (IPT) as a treat-
ment for major depression (Klerman et al., 1984) as well as for other psychi-
atric disorders (Weissman et al., 2000; Weissman et al., 2007). For lack of 
space, this book cannot accommodate the detail of those manuals in its focus 
on PTSD. Instead, this chapter outlines the basic principles of IPT as a time- 
limited, diagnosis- targeted treatment for psychiatric disorders. It thus neces-
sarily compresses a complex treatment— IPT is not the most complicated of 
psychotherapies, but no psychotherapy is simple. (Readers may want to con-
sult the standard IPT manuals [Klerman et al., 1984; Weissman et al., 2000; 
Weissman et al., 2007] for greater detail.) Chapter 4 of this book, describing 
the adaptations of IPT for treating patients with chronic PTSD, incorporates 
the basic IPT principles listed here.
Interpersonal Psychotherapy, developed in the 1970s by Myrna Weissman, 
the late Gerald L.  Klerman, and their colleagues at Yale and Harvard uni-
versities, was initially intended as a treatment for major depressive disorder 
(Klerman et al., 1984; Markowitz & Weissman, 2012). IPT not only acutely re-
lieved depressive symptoms better than a control condition and comparably to 
medication, but on follow- up, IPT improved interpersonal functioning, which 
medication alone did not (Weissman et al., 1976). Combined treatment with 
IPT and medication proved better in treating major depression than either 
alone (DiMascio et al., 1979). A series of randomized controlled clinical trials 
 
 

---

A Pocket Guide to IPT 
37
has since repeatedly demonstrated its efficacy, not only for that disorder, but 
for unipolar depression in various treatment populations, for eating disor-
ders (Weissman et al., 2000), as an adjunctive treatment for bipolar disorder 
(Frank et al., 2005), and to a lesser degree, for some anxiety (Markowitz et al., 
2014) and other disorders. Researchers have sequentially adapted IPT for dif-
ferent diagnoses, cultural populations of patients, and treatment formats. In 
general, these adaptations have been detailed in treatment manuals tailoring 
the basic IPT treatment to the particular clinical circumstance. This book ex-
pands upon the treatment manual we used in our NIMH- funded research trial 
(Markowitz et al., 2015).
IPT is based on theories of attachment and interpersonal functioning de-
rived from Harry Stack Sullivan (1953), John Bowlby (1969), and others 
(Klerman et al., 1984; Markowitz et al., 2009; Lipsitz & Markowitz, 2013). The 
IPT approach emphasizes human beings as social animals and links patients’ 
feelings to their interpersonal context. IPT balances interpersonal theory 
with practical, pragmatic, clinically informed interventions. When Gerald 
L. Klerman, Myrna M. Weissman, and their colleagues were developing the 
treatment in the 1970s, they built it upon empirical data about interpersonal 
interactions and the relationship of mood disorders to life events (Markowitz &  
Weissman, 2012).
BASIC PRINCIPLES
Klerman and Weissman knew that depressed individuals withdrew from 
social interaction, spoke less, did less, and functioned less well than others 
(Klerman et al., 1984). Depressed individuals become passive, resigned, help-
less, and hopeless. Klerman and Weissman also knew that interpersonal 
events frequently triggered depressive episodes. Based on these theories and 
data, Klerman, Weissman, and colleagues developed a time- limited, diagnosis 
(namely, major depression)– targeted treatment that used these core principles:
  1.  Depression is a medical illness
  2.  Life events affect mood, and 
vice versa