Interpersonal Psychotherapy for Posttraumatic Stress Disorder

verbalizing
 the feelings that the patient has 
newly acknowledged, and the feelings that you have just helped the patient 
see as a reasonable, normal, meaningful emotional response. Frequently, this 
means asserting a wish (“I’d like to do this”) or confronting a negative beha-
vior (“It bothers me when you do that”).
As treatment progresses, patients are increasingly likely to come to their 
session reporting positive encounters: interchanges where they have expressed 
their needs and received a positive response from others, or have confronted 
unwanted behavior and had the other person apologize or back off. When this 
happens, it’s important to congratulate the patient, reinforcing adaptive be-
haviors; and to underscore the link between successful interpersonal behav-
iors and feeling better.
“Great work! 
…
 So how did you manage that? 
…
 Do you feel comfort-
able using that approach in future?”
 6. 
Role play.
 Once the patient has come up with a feasible option, you 
have the opportunity to 
role play
 so that the patient can rehearse it. It’s 
often best to launch spontaneously into a role play, with you enacting 
the other person, rather than emphasizing the creation of an artificial 
situation by saying, “Let’s role play.” Use the situation and dialogue the 
patient has just provided to recreate the encounter. Hopefully the pa-
tient will take it in a new direction. Once the patient has done so, you 
can stop the role play and recapitulate it, eliciting the patient’s reaction 
to both the 
content
 and the 
tone
:
“How did you feel [saying that]?”
(That is, what was it like speaking in a more direct or assertive way?)
“Did you say what you wanted to say?”

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Middle Phase 
75
(If not, what would the patient add or say differently?)
“What about your tone of voice? How did you think you came across?”
Some patients worry that expressing anger shows that they’re “mean” or “bad.” 
Role plays give them the chance to practice modulating their tone, so that it’s 
neither too deferential and meek nor too angry and explosive. Based on the 
patient’s self- assessment of the role play, and judicious comments you might 
want to add (best stated in question form: “What did you think of the way you 
handled X?”), you can repeat the role play until the patient feels comfortable 
with the intervention.
It’s also worth exploring contingencies. You might ask:  “How is Mark 
likely to respond if you say that?”
The patient may come up with unexpected answers, which you can incorpo-
rate into subsequent role play. If the patient’s partner has a tendency to get too 
angry, how can the patient respond to that? (“What options are available?” can 
lead to further role play.) The more contingencies you cover, the more practice 
the patient gets, and the more comfortable the patient is likely to feel turning 
role play into interpersonal action between sessions.
Therefore, whether the patient reports a positive or negative event and mood 
in response to the session’s opening question, the session should lead to an ex-
ploration of interpersonal functioning and a strengthening of interpersonal 
skills. Even bad reported outcomes should result in constructive exploration 
and new plans. Do not hesitate to congratulate patients for achievements (they 
need that reinforcement) nor hesitate to sympathize with setbacks. Either in-
tervention, if delivered with authentic feeling, helps build the therapeutic al-
liance. Recognize that the patient is suffering and that taking interpersonal 
risks is brave. No formal homework is assigned in IPT, but the framework of 
the treatment focus itself constitutes a task: e.g., the need to resolve a role tran-
sition in the time- limited therapy. Thus implicit in role play is the idea that the 
patient will want to use it, sooner or later, in life.
The focus of treatment therefore tends to rest on daily encounters with sig-
nificant others or strangers: how the patient has handled an interaction with 
a family member, a friend, a co- worker, a doctor, or some man on the street 
or in a convenience store. Focus on the particular to elicit affect. Ask patients 
to name people in encounters rather than using anonymous pronouns. Ask 
for actual dialogue rather than summaries of exchanges. These small encoun-
ters provide an opportunity for the patient to express feelings and needs in a 
manner appropriate to the situation, which should make these encounters go 
better and leave the patient feeling that the world is safer and more manageable 

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76 
I P T   F O R   P T S D
than PTSD has led him or her to believe. When these encounters go well, the 
therapist reinforces the patient’s adaptive interpersonal skills, always making 
the link between mood and life events (“You handled that really well! So no 
wonder you’re feeling a little better!”).
The patient will return the next week, to be greeted by the same opening 
question. This should yield another interpersonal situation, hopefully linked 
to the central problem area, an update on the previous session. If the patient 
handled the situation well, he or she may be feeling better, and you can rein-
force gains. If not, you can sympathize, re- strategize, and encourage the pa-
tient to keep working on the interpersonal issues. I encourage patients to “Live 
dangerously!”— not to take reckless chances, but to take appropriate interper-
sonal risks that may nonetheless feel dangerous at first.
To recap, the general progression in sessions should be as follows:
  1.  Identify a recent, affectively charged event and determine its outcome.
  2.  Elicit the patient’s feelings in and about this event. Helping the patient 
name his or her feelings cultivates a useful skill. Again, don’t interrupt 
powerful affects— let the patient experience strong emotions as useful, 
meaningful feelings before you intervene.
  3.  Validate those feelings. Usually you will be able to empathize and 
support the patient’s feelings. The emotions an event elicits tend to 
be intuitively predictable. In the instance where a patient reports an 
odd or confusing reaction to an event, it is worth exploring the feel-
ings, understanding the situation from the patient’s perspective, and 
validating what you can in that reaction. If the patient brings up guilt 
or a PTSD- related response, you can label these as symptoms of the 
syndrome.
  4.  This depends upon how the reported encounter went:
 a.  If things have gone well,