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problem areas and focus of treatment
as a role dispute— her ongoing conflict
with her mother; and a role transition— her search for a new job. The patient
accepted these foci.
The middle sessions explored the potential for improving Deborah’s rela-
tionship with her mother, addressing her conflicts with her boss, and pursuing
a new job. Working from recent and anticipated interactions, therapist and
patient
explored how the patient felt in those situations
, naming and validating
her feelings. They then considered what
options
she had for handling these
situations. Initially tentative, the patient was able to suggest feasible options
with the therapist’s encouragement. Next, they
role- played
different options
for communicating her needs to her mother, as well as to work colleagues and
peers. They also role- played phone conversations inquiring about job opportu-
nities and responding to questions in job interviews. Addressing the patient’s
current life situations, the therapist helped her better understand her feelings
and needs and express them to others, as well as present herself more effec-
tively on job interviews.
The therapist continually related Deborah’s currently feeling vulnerable,
mistrusting others, withdrawing from others, and excessive anger reactions
to having been traumatized: “These are part of PTSD.” At the same time, the
therapist empathized with Deborah’s understandable need to protect herself
against being vulnerable to others. She related Deborah’s difficulty in pri-
oritizing and asserting her needs, and her negative self- image, to PTSD and
depression. Like many who have been abused, Deborah perceived herself as
damaged and feared that others would be see her as damaged or deduce that
she had been abused. The therapist related this misperception to having been
traumatized— PTSD— and reminded her that abuse, while part of her life ex-
perience, did not have to define her.
Role Transitions
97
In addition to working on the focal problem areas, the therapist encour-
aged Deborah to work on current relationships and forming new ones, at the
same time empathizing with her fears of getting hurt and rejected. The ther-
apist encouraged her to engage in activities that she had once enjoyed. By the
end of the week 7, her PSS- SR score had fallen to 55, a clinically meaningful
improvement.
One crucial moment in the therapy came after therapist and patient dis-
cussed Deborah’s anger at her boss for his extremely harsh behavior toward
her. The therapist validated the patient’s tentative expression of angry feel-
ings in the session: “Anyone would feel angry being treated that way.” The
therapist
normalized
Deborah’s reaction. As she became more confident in
her reaction to this mistreatment, the patient decided to lodge a complaint
with the human resources department of her company. Her boss backed off
and apologized, life at work became much less threatening, and Deborah felt
better. She continued to look into alternative job options and to polish her
interviewing in sessions.
The other important theme concerned her relationship with her mother.
Deborah described feeling angry at her mom for not protecting her from her
stepbrothers or ensuring they were punished for molesting her, yet reported
feeling guilty for feeling angry, as she saw her mother as fragile and in a diffi-
cult position. The therapist validated the patient’s anger at her mother and re-
lated the excessive guilt to depression. The therapist and Deborah role- played
expressing Deborah’s wish that her mom be more supportive by asking the
stepbrothers to stay away from the house when she visits. She then was better
able to communicate her needs more directly to her mother. Her mother sym-
pathized with her feelings but replied that she could not talk about the past
further. The mother stated that she would try but could not promise to keep
the stepsons out of the house. In a subsequent session, the therapist validated
the patient’s wish that her mother be more supportive, as well her disappoint-
ment that her mother continued to provide less support than she wanted. The
final sessions explored whether there was an impasse in Deborah’s relationship
with her mother, and what the patient’s further options were for dealing with
it. Therapist and patient also reviewed the patient’s gains in the treatment, her
better handling of social interactions, and the consequent improvement in her
symptoms and overall wellbeing.
At the end of treatment, Deborah felt more accepting of her mother’s lim-
itations and was able to speak to her with less distress. She felt more capable
in dealing with her boss and more confident on job interviews. She reported
improved relationships with her peers, was socializing more and had resumed
activities such as dancing. Furthermore, she mentioned that she was no longer
getting off crowded trains before her stop.
98
I P T F O R P T S D
By her final, week 14 session, Deborah’s PSS- SR score had fallen to 6, an es-
sentially asymptomatic status. At six month follow- up, her PSS- SR score was 15,
reflecting maintenance of her acute symptomatic improvement.
This case used two interpersonal foci, a role transition and a role dispute,
situations that commonly co- occur. It would probably have been possible to
cover much of the same ground in treatment under a single focus. Regardless,
the patient clearly benefitted from this approach.
Role transitions can take many forms, depending in part on the patient’s
history and the nature of the abuse they suffer. The above examples hopefully
illustrate the IPT approach to treating patients with PTSD: the focus is on the
patient’s improving the patient’s affective awareness and current interpersonal
functioning rather than on reconstructing the trauma and exposure to trauma
reminders.
“Give sorrow words. The grief that does not speak
Whispers the o'erfraught heart and bids it break.”
— Shakespeare,
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