Interpersonal Psychotherapy for Posttraumatic Stress Disorder

Diagnose
 PTSD
  •  Diagnose the interpersonal context: take an 
interpersonal inventory
  •  Link them in a 
formulation
, and get the patient’s explicit agreement
  •  Consider pharmacotherapy
  •  Give the patient the 
sick role
  •  Set the 
time limit
  •  Set the 
framework
 for treatment
  •  Begin sessions with: 
“How have things been since we last met?”
  • Provide 
psychoeducation
  •  Address contingencies

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6
IPT  for PTSD— Middle Phase
“My tongue will tell the anger of my heart
Or else my heart, concealing it, will break. …”
—Shakespeare,
 The Taming of the Shrew, IV, 3
Once you have obtained the patient’s explicit agreement to the formulation, 
you enter the second phase of treatment. This comprises roughly sessions  
4– 11. You and the patient focus on the interpersonal problem area (
grief, role 
transition,
 or 
role dispute
) in order to try to improve the patient’s emotional 
read of interpersonal encounters and the patient’s interpersonal functioning. 
Successful experiences in handling social situations (e.g., a successful encounter 
with a co- worker or family member) are likely to give the patient a greater sense 
of control over the environment, and symptomatic relief. The IPT manual 
(Weissman et al., 2007) describes specific goals and strategies for each of the 
problem areas. These do not meaningfully differ in their application to PTSD.
For 
grief
 (
complicated bereavement
), the goals include facilitating mourning 
(catharsis) and finding new relationships and activities to fill the void that the 
death of a significant other has left. Whereas bereavement itself is not a psy-
chiatric disorder, complicated bereavement is. Symptoms may include those 
atypical of usual grief, such as excessive guilt and suicidal ideation. The death 
of a significant other may be associated with uncomfortably ambivalent feel-
ings about the other person and the lost relationship, leading the patient either 
not to grieve at all or to take on the role of a chronic professional mourner, too 
guilty to see a moment of calm or pleasure as anything but a betrayal of the 
deceased. Neither of these stances is adaptive.
As in IPT for major depressive disorder, IPT for grief in PTSD explores the 
patient’s feelings, positive and negative, about the lost person. The cause of 
 
 

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Middle Phase 
69
death is likely to be related to (or may be) the traumatic event defining the 
patient’s syndrome. Rather than focusing on the trauma 
per se
, the therapist 
focuses on the relationship. It is usually easier for patients initially to describe 
what they liked and what they miss about the lost person and relationship. The 
therapist pulls for affect, and gradually explores and validates less positive feel-
ings as well. The message is: It’s okay, even natural, to dislike or hate someone 
who has died; it’s expectable to have mixed feelings about people, perhaps es-
pecially the people you are close to. And talking about your feelings may be 
painful, but it isn’t dangerous, and dealing with them may prove a relief.
As these feelings emerge, 
it is important for you to resist the anxious temp-
tation to interrupt powerful emotions: your job is to model for the patient that 
strong feelings are tolerable, understandable, and will pass.
 The patient gener-
ally experiences catharsis in dealing with the loss and understands it more 
fully. At the same time, therapist and patient work on how the patient is hand-
ling interpersonal encounters in current daily life and how PTSD may be ad-
versely influencing them. Patients, who typically feel adrift after the traumatic 
death of a loved one, need to find a new direction and substitute relationships, 
and generally begin to accomplish this during the course of treatment.
In a 
role dispute
, the patient is overtly or covertly struggling with a significant 
other: a spouse, family member, friend, boss, or co- worker. Frequently this is a 
consequence of, or at least exacerbated by, the traumatic event. Therapist and 
patient determine whether or not the relationship is truly at an impasse (as the 
patient generally perceives it to be), and whether there are interpersonal strate-
gies the patient can use to resolve it. What is the dispute? What does the patient 
want? What has he or she tried to do to resolve it? What else can be done?
The reason IPT calls these interpersonal conflicts “role disputes” is that they 
contain a distortion of the axiom that good relationships are based on bilateral 
compromise. No two people agree on everything, so each compromises to some 
degree for the other, hopefully in a balanced 
quid pro quo
. In some relation-
ships, however, this relationship becomes polarized: one person may demand 
satisfaction of his or her needs, and the other may provide that satisfaction at 
undue cost to his or her own. You can see how a depressed or anxious patient, 
feeling inadequate, unlovable, and burdensome, might have trouble asserting 
his or her needs and denying those of another person. Yet patients suffer, often 
feeling resentful and unappreciated— but helpless— in such relationships. IPT 
helps such patients by first eliciting and validating their wishes and dislikes, 
then using role play to prepare the patient for trying to 
renegotiate the rela-
tionship into a fairer balance
. The goal of IPT becomes an attempt to improve 
the role dispute or else, failing that, ultimately to end it, which precipitates a 
role transition. Role disputes, which are conducted almost as unilateral couples 
therapy, are excellent opportunities for developing or redeveloping social skills.

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70 
I P T   F O R   P T S D
In a 
role transition
, the patient needs to recognize that 
what feels like chaos is a 
transition
; then mourn the loss of the old role and relinquish it, while recognizing 
and adapting to the potentials of the new role. We have found that even patients 
who suffer objectively bad events (notably, learning that they have HIV infec-
tion [Markowitz et al., 1998]) can come to see the bright side of such transitions. 
Role transitions are inherent in PTSD: a distressing life event has occurred, after 
which a patient views life differently, and for the worse, and after which he or 
she has developed the symptoms and interpersonal difficulties of PTSD. Again, 
treatment focuses on the interpersonal consequences of the loss/ change and how 
the patient can regain social supports and interpersonal competence.
As previously noted, the fourth interpersonal focus, 
interpersonal deficits
, 
defines patients who lack life events. This is the least well defined IPT cate-
gory and carries the poorest prognosis. An advantage of treating patients with 
PTSD is that, because they have by definition a defining life event, this cate-
gory can be avoided altogether.
Patients with PTSD, like many patients with major depression or dysthymic 
disorder, often feel that feelings like anger are “bad,” and have trouble expressing 
or even acknowledging them. Yet such affects are inevitable human responses, 
and they potentially inform patients of what is happening in their interpersonal 
situations. They frequently arise during role disputes. People feel angry when 
they have been attacked or offended; ignoring or suppressing this feeling often 
leaves them feeling anxious and uncomfortable. Moreover, the interaction with 
the other person has ended uncomfortably, and whoever is bothering them will 
receive no cue from the patient that their behavior is hurtful and unacceptable. 
The undesired interpersonal pattern is therefore likely to continue.
Therapists should