Interpersonal Psychotherapy for Posttraumatic Stress Disorder

formulation
 
(Markowitz and Swartz, 2007) that links the diagnosis to the patient’s 

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60 
I P T   F O R   P T S D
life situation. You might begin this by first complimenting the patient 
on his or her help in gathering the data you are about to summarize:
“You have given me a lot of information so far. I think I understand what 
has happened to you, but can I ask you if I’ve gotten it right?”
Then, for example, you could say:
“You have PTSD, an illness that developed in response to the terrible attack(s) 
you suffered. Horrible events like yours can really change your outlook and 
your life: if you experience something painful enough, anyone can develop 
PTSD. But it’s not your fault, and it’s a treatable disorder.” [Here you might 
describe some of the PTSD symptoms the patient has recounted.]
“As a consequence of PTSD, you now seem to have trouble trusting 
all sorts of relationships and situations you face. We call this change the 
trauma causes a 
role transition
. Your life has felt out of control since then. 
If you can learn to understand PTSD and the transition you’re going 
through— a transition that requires dealing with the interpersonal con-
sequences of your trauma— you can do something about it. 
We’ll focus on 
how past trauma is interfering with your current interactions with other 
people.
 I suggest that we work on how you can use your emotional re-
sponses to situations to handle this during the remaining 12 weeks of 
treatment. Your feelings can help you decide who’s trustworthy and who 
isn’t. If you can get things under control, your PTSD symptoms may well 
improve, too. Does that make sense to you?”
Or: “You have PTSD, a treatable illness
… 
. Your continuing distress 
seems to have something important to do with the 
role dispute
 you’re 
having with your family, whom you’ve felt alienated from and who also 
seem to have been treating you differently since you were raped. I suggest 
that we work on seeing how you can solve this situation with your family 
over the remaining 12 weeks of treatment. If you can resolve this dispute, 
you will probably feel a lot better; and your PTSD symptoms may well 
improve too. Does that make sense to you?”
Or: “Witnessing the death of your child and feeling you couldn’t do  
anything to prevent it was a horrible event. It’s one of the worst life events, 
the kind of trauma no parent should have to endure, and it’s not sur-
prising that you’ve had trouble getting over it. As a consequence of this 
extreme trauma, you’ve developed PTSD. You’ve been feeling numb, 
and worry about how you feel, and you’ve tried to keep it to yourself, but 
things have been getting worse and worse.
“So your PTSD is connected to this terrible event. We call what you’re 
going through 
complicated grief
, and it’s taken over your life. I suggest 

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Initial Phase 
61
that we spend the remaining 11 weeks of treatment helping you come to 
terms with your feelings, and figuring out how to proceed in this excruci-
ating situation. Does that make sense to you?”
This formulation defines a focus for the remainder of the treatment. 
The pa-
tient must explicitly agree
 with the therapist on this formulation. Once the 
patient does, the therapist may steer him or her to that focus from session to 
session. The formulation works in both directions: PTSD symptoms inhibit 
social functioning, which in turn reinforces PTSD avoidant symptoms and 
sense of social distrust.
If a patient were to disagree with your formulation, you could negotiate a 
different focus. It’s important that you recognize the patient’s input— good that 
the patient asserts herself!— and that you and the patient reach an agreement 
on the goal of therapy. In practice, however, it’s extremely rare for patients to 
disagree with a formulation. IPT interpersonal problem areas generally make 
sense to patients (Markowitz et al., 2007). Life events, particularly traumatic 
ones, are undeniable. No patient in either of our PTSD studies ever disagreed 
with the focus.
PHASE 2: SE T TING THE FR AME WORK 
FOR TRE ATMENT
A second aspect of the initial phase is to explain the format of IPT to the pa-
tient. Keep in mind that patients with PTSD come to treatment feeling over-
whelmed, assaulted, and out of control. They fear unpleasant surprises around 
every corner; they never know what’s coming next, but they anticipate that it 
will be bad. Under these circumstances, your job is to make the office a safe 
place, to preclude as many surprises as possible.
You can do this in several ways. Just taking a professional stance, elicit-
ing a history, diagnosing the disorder, and linking it to the patient’s inter-
personal context in the formulation should emanate a sense that you’ve dealt 
with PTSD before, know how to treat it, and know that it’s treatable. If you 
are calm, caring, attentive, respectful, and understanding (using the “common 
factors”— see the end of this chapter), that will help, too. By structuring the 
framework of treatment for the patient, letting him or her know what to 
expect, you can further defuse fears about what will happen in treatment and 
communicate hope for improvement.
  A.  Explain that