Interpersonal Psychotherapy for Posttraumatic Stress Disorder

Table 5.1.
  The Common Factors of Psychotherapy
  •  Affective arousal (Response)
  •  Feeling understood by therapist (Relationship)
  •  Framework for understanding (Rationale)
  •  Expertise (Reassurance)
  •  Therapeutic procedure (Ritual)
  •  Optimism for improvement (Realistic)
  •  Success experiences (Remoralization)
Note
:
 Adapted from Frank, J. (1971). Therapeutic factors in psychotherapy. 
American 
Journal of Psychotherapy, 25
,  350– 361.

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66 
I P T   F O R   P T S D
fragile— in the forms of both better understanding of their feelings 
and the ability to use them to improve interpersonal encounters and 
to resolve their presenting life crisis.
For these patients, 
normalizing negative affects
 is crucial. What patients may 
see as “bad” or inappropriate feelings are often appropriate and useful sig-
nals. Anger may be an appropriate response to a provocation or attack. It’s 
not “mean” or aggressive to defend oneself against an attack; it’s self- defense. 
A little selfishness is healthy, not “selfish” in a bad, overweening way; if you 
don’t express your needs, you’re unlikely to get them met. Being assertive is 
not the same thing as being pushy or aggressive: it’s simply expressing one’s 
needs and desires. Helping patients understand such feelings as social signals 
is a gift beyond that of symptomatic response. It gives patients a different and 
more comfortable way of looking at themselves, relationships, and the world.
The patients you treat will have survived horrific events and deserve caring 
attention. At the same time, no matter how bad their experience, you can 
provide therapeutic optimism: they 
have
 survived, they can grow from the 
painful experience, this is a chance for them to recover their lives. (The idea 
of being a 
survivor
, and in some ways stronger for it, is one positive aspect 
that can be used in reframing a posttraumatic role transition.) Our prelimi-
nary study (Bleiberg & Markowitz, 2005) showed that IPT helped badly, mul-
tiply, and chronically traumatized patients, so there was reason to believe it 
would help patients in the randomized controlled trial. It worked there, too 
(Markowitz et al., 2015). IPT also encourages the kind of 
success experiences
 
that help patients feel they have more control over their lives, and that help 
patients get better.
While in the role of caring ally, you want to focus treatment on the patient’s 
current life and relationships 
outside
 the office, not on your relationship with 
the patient itself.
Psychoeducation
, a process that may proceed throughout treatment, should 
leave the patient with an understanding of PTSD and its treatment. It should 
begin in the first session as part of the discussion of what PTSD means. Don’t 
go into long- winded speeches about this: provide information at judicious mo-
ments, in digestible packets. The IPT- PTSD handout (see Appendix) can rein-
force this process. Psychoeducation involves several points:
  A.  First, PTSD is a disorder, but it’s an understandable response to a 
dreadfully upsetting trauma. If you’re hurt badly enough, you with-
draw, hunker down, and just try to survive. Suppressing emotion 
may be necessary for immediate survival, as may hypervigilance. 
Unfortunately, such behavior may persist long past its point of 

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Initial Phase 
67
usefulness. As the patient comes to terms with life after the trauma, he 
or she can (re)gain a social equilibrium and feel better. Having a treat-
able diagnosis is not nearly so bad as feeling that there is something 
inherently defective about you as a person.
  B.  It is helpful for the patient to understand the emotional, physical, and 
cognitive 
symptoms
 of PTSD. You may review these with the patient 
by reading the diagnostic criteria section of the 
DSM-5
 (American 
Psychiatric Association, 2013, pp. 271– 272; Chapter 2, Table 2. 1 of 
this book) together. Repeating the CAPS interview or other symptom 
severity ratings periodically during the treatment will also reinforce 
the nature of the symptoms. Reviewing the social consequences 
of PTSD— damaged relationships, etc.— is crucial from the IPT 
perspective.
  C.  The patient may also be reassured that PTSD is 
treatable
. A number 
of treatments work. IPT has done very well so far. Even symptoms 
that IPT does not directly address (e.g., flashbacks) tend to improve as 
the syndrome responds to IPT. You can’t promise that IPT will help 
the patient— no treatment works for everyone— but you are optimistic 
that you can help the patient regain his or her life after this tragedy. 
Even if IPT should not work, there are alternative psychotherapies and 
medications that may address the symptoms. There is clinical 
hope
.
The goal of this initial phase of IPT is to complete the history- taking and to set 
the framework for the treatment as efficiently as possible, so that a maximal 
amount of time remains to actually treat the disorder in the middle phase. 
The more socially uncomfortable, anxious, disorganized, or mistrustful your 
patient is, the longer it is likely to take to gather a history and to establish the 
basic therapeutic alliance needed to proceed. Table 5. 2 summarizes the tasks 
of this phase.
Table 5.2.
  Tasks of the Initial Phase of IPT- PTSD
 •