Interpersonal Psychotherapy for Posttraumatic Stress Disorder

Next Steps.
 Even much improved patients sometimes feel shaky in leav-
ing treatment. Therapist and patient discuss risks of symptom recurrence and 
forecast ways of coping with future challenges. The patient should optimally 
 
 

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Termination Phase and Maintenance 
127
leave treatment with a new recognition of the impact of the trauma he or she 
has suffered, its interpersonal sequelae, and with gains in and tools for further 
improving interpersonal functioning.
Termination is a time to anticipate future problems the patient may face and 
to discuss interpersonal coping strategies to deal with them. “What problems 
can you anticipate arising in future?”
For patients whose PTSD has really improved, the prognosis may actually 
be better than it is for major depression (Judd et al., 1998), which tends to 
recur in the absence of maintenance treatment (Frank et al., 1990). Patients 
whose PTSD gets better generally stay better unless they suffer a new trauma. 
A patient who understands how to handle interpersonal stressors by calling 
on social supports to express their feelings and gain validation may well be 
less likely to suffer a recurrence. Some patients may benefit from a shift in 
treatment from the current focus to treating comorbid disorders, or referral to 
another therapist for that purpose.
Patients who do not improve in acute (14- week) IPT for PTD, or who 
show minimal improvement but have considerable residual symptoms and 
need ongoing further treatment, should be referred appropriately. For IPT 
non- responders, this might include pharmacotherapy with serotonin re-
uptake inhibitors (SRIs) and psychotherapies such as Prolonged Exposure, 
Cognitive Processing Therapy, or another empirically validated treatment. In 
our randomized treatment study, we offered non- responders to 14 weeks of 
study treatment a choice of one of the other study therapies (IPT, Prolonged 
Exposure, or Relaxation Therapy), medication, or a combination thereof. 
Many of those patients subsequently responded to this second course of 
treatment.
When patients with PTSD (or any diagnosis) do not improve, it is impor-
tant to help them see that this lack of improvement is not a personal failure, 
but that the 
treatment
 has failed: no approach works for everyone, and there 
are alternative, effective treatments available. The approach is comparable to 
a failed pharmacotherapy trial: blame the treatment, not the patient, and find 
a different treatment that might work better. Under such circumstances, it is 
important to help patients recognize any gains they have made, and to help 
them fight off demoralization that might keep them from proceeding toward 
treatments that might help.
One way to do this in IPT is to review interpersonal progress, which may 
well have been significant: How has the patient learned to handle relation-
ships differently? What skills has the patient applied in dealing with people 
with whom he or she had previously been detached and distant? The patient 
who has progressed in this area has fulfilled his or her part of the bargain 
in IPT:  this is what we have been asking the patient to do. Symptoms are 

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128 
I P T   F O R   P T S D
supposed to have improved as a result: if they have not, then (1) the patient still 
has gained some interpersonal skills, which is good; and (2) it should be clear 
that it is the therapy itself that has failed to deliver its promise, not the patient.
It is reasonable to ask a patient who is terminating treatment to check in 
with you in future. This simply adopts the general practitioner’s approach to 
treatment: “Now that you’re better, you can go home; if you feel ill again, please 
come back.” This stance follows from the IPT emphasis that illness is treatable 
and not the patient’s fault. You can also ask whether, if it’s not an imposition, 
the patient could check in with you in 6 or 9 or 12 months to let you know how 
things are going. Most patients are happy to do so. This provides a sense of 
continuity even after treatment has formally ended, and indicates the thera-
pist’s ongoing interest in the patient’s well- being.
MAINTENANCE TRE ATMENT
Several studies at the University of Pittsburgh have demonstrated that main-
tenance IPT, conducted as infrequently as once a month, can protect patients 
from recurrence of even highly recurrent major depressive disorder (e.g., Frank 
et al., 1990; Frank et al., 2007; Reynolds et al., 1999). Some patients may benefit 
significantly from acute IPT for major depression, yet remain at high risk of 
recurrence, either because of a history of multiple prior episodes or because of 
high residual depressive symptoms. For example, they may have improved in 
treatment from an initial Hamilton Depression Rating Scale score of 29 to a 
post- treatment score of 14, but at 14 remain on the cusp of major depression. 
For such patients, who already know the approach and their therapists, main-
tenance treatment makes clear clinical sense, and research has validated this. 
For such patients, the IPT approach is to terminate acute treatment and then 
re- contract for continuation or maintenance IPT: for example, once- monthly 
sessions for three years, or twice monthly sessions for two years.
How about ongoing treatment for PTSD? Many patients with PTSD im-
proved in our IPT study, and yet many did not fully recover and might have 
benefitted from maintenance IPT therapy. Indeed, most patients with chronic 
PTSD who receive any empirically validated treatment do not remit and might 
benefit from further treatment. Our research trials simply tried to determine 
whether IPT worked acutely, a necessary first step before considering longer 
term treatment. Now that we have an initial positive answer supporting IPT, it 
would be helpful to know whether maintenance IPT works— but absent data, 
we simply cannot say. Because the National Institute of Mental Health is not 
funding expensive maintenance treatment trials these days, we will probably 
have no answer in the near future.
 

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Termination Phase and Maintenance 
129
In clinical practice, it makes intuitive sense for a patient with PTSD who 
has improved in IPT but remains symptomatic to continue treatment with a 
therapist whom he or she has come to trust. To do so, the therapist should first 
conclude acute treatment as originally contracted, then set up a new schedule 
incorporating the patient’s preference. How frequently would the patient 
like to meet? For how long an interval into the future? And with what goals? 
Maintenance IPT has the flexibility of switching problem areas to meet new 
interpersonal issues that may arise over the course of time. This maintenance 
approach has worked well for PTSD patients in my private practice who ben-
efitted from acute IPT.

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11
Difficult Situations  
and Special Circumstances
“The man who in a fit of melancholy kills himself today would have 
wished he lived had he waited a week.”
— Voltaire,
 Philosophical Dictionary
Like many individuals with other psychiatric diagnoses, patients with PTSD 
present potential clinical risks. The therapist needs always to keep these in 
mind in order to minimize them. Our treatment study minimized risk to some 
degree through study exclusion criteria (excluding substance dependence, for 
example), frequent evaluation of symptoms, and encouraging patients to tell 
us of crises.
DANGEROUSNESS