Interpersonal Psychotherapy for Posttraumatic Stress Disorder

reclaim your life
, not to be cheated by these two disasters 
from living life to its fullest. We call what you’ve been through a 
role 
transition
: distressing things have happened that have changed your 
life and your sense of whom you can trust. I suggest that we use the 
remaining 11 sessions of this treatment to focus on how the PTSD is 
interfering with your feelings and your relationships, so that you can 
decide whom to trust and whom not to. Does that make sense to you?
It did. Thus they agreed on a formulation that defined the remainder of the 
treatment. IPT focused not on Martina’s traumas— which were never directly 
mentioned again— but on the consequences of the traumas on her relation-
ships. These, perhaps never strong, were further distanced in the context of 
PTSD. The therapist set treatment as 14 consecutive 50- minute weekly sessions 
and gave the patient the sick role:
No one is at her best after going through something like this. You’ve 
been hit hard, and your symptom scores show it. You can expect 
that it may be hard to function; give yourself a break for what you 
don’t feel up to, just as you would if you had the flu. In fact, PTSD is 
a lot worse than the flu. As we work on these issues, you’re likely to 
gradually feel better and to function better. We’ll be repeating the 
rating scales at regular intervals to make sure you are getting better.
With their agreement on the formulation, Martina and her therapist entered 
the middle phase of IPT. Martina continued to appear agitated and hesitant, 
acknowledging some anxiety and depression but otherwise reporting detach-
ment from her feelings. The therapist began each session asking,
“How have things been since we last met?”

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This tended to elicit minor daily events, mainly at work, inasmuch as Martina’s 
always impoverished social life had atrophied in the setting of PTSD. The ther-
apist then asked:
“And how did that make you feel?”
Martina: I don’t know. I didn’t feel anything
… 
. Maybe a little upset.
The therapist would then explore: “What kind of upset? 
…
 What do 
you call that feeling?” 
And, having elicited it: “Does it make sense, is that a reasonable feeling 
to have had?”
It turned out that Martina did have one friend at her job, Jamie, who went on 
a week’s vacation a few weeks into the therapy. Martina had agreed to cover 
her which entailed doubling her work load. Jamie then called at the end of the 
week, asking if Martina could cover for a second week. Martina acquiesced. 
In discussing this in therapy, she said it was “no big deal.” When, at the end of 
the second week, the friend called and asked for yet another week of coverage, 
Martina began to feel taken advantage of.
Martina: I want to be nice to her, but I’m starting to feel a little 
uncomfortable about this. [Silence]
Therapist: Tell me.
Martina: Well, she seemed nice at work, and I wanted to be nice, too, 
but I’ve been working overtime for her and she doesn’t really seem to 
notice, to appreciate it.
Therapist: It does seem that way. So what feelings does that bring up?
Martina: Oh, nothing. I don’t know.
Therapist: [raises eyebrows and waits]
Martina: I guess it bothers me a little.
Therapist: What do you call that feeling?
Martina: I guess I’m a little frustrated, a little 
…
 annoyed.
Therapist: Huh. And does that seem a reasonable reaction, with 
Jamie asking for more and more and not seeming to notice what it 
means for you?
Martina: 
…
 Yes, I guess. I’m a little bit mad at her. But I don’t like 
that feeling. Never have.
Therapist: Tell me about that.
Martina: I just don’t feel comfortable. I feel like I’m mean, not a good 
person.
Therapist: Are you feeling that frustration/ anger out of the blue, or 
do you think there’s a reason for it?

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Role Transitions 
83
They discussed whether Jamie had transgressed good behavior, “stepped over 
the line” in asking a little too much of Martina. The therapist worked to nor-
malize the feeling:
Therapist: Maybe if you get angry at someone for no reason, that’s 
being mean. But often anger is a useful social signal, it tells you 
that someone else is misbehaving. In a way, that’s how you 
know
 
someone’s not treating you well: you feel annoyed or angry.
Martina: I’m not very comfortable with this.
Therapist: Everyone’s a little uncomfortable about anger, and PTSD 
makes it still harder to deal with— strong “negative” emotions like 
anger can feel overwhelming. But we’re trying to focus on whom you 
can trust, and this is one way to figure it out.
Having normalized the anger, the therapist asked what Martina could do 
with it:
Therapist: So your feelings are telling you something about how 
Jamie’s behaving— or misbehaving. What can you 
do
 about it? 
…
 
What options do you have?
Martina: I don’t know. I don’t think there’s anything I can do.
Therapist: [silent]
Martina: I guess I can just give up on her as a friend.
Therapist: That’s certainly one option. But you’ve said that Jamie’s 
the person you’ve been friendliest with at work. Before you give up on 
her, do you have any other options?
With a little gentle prodding, they came around to the idea that Martina could 
put her feelings into words.
Martina: I guess I could say something
… 
.
Therapist: Good idea! You could put your feelings into words. What 
might you say?
Martina: I don’t know, I’m uncomfortable
… 
. “Jamie, it’s not that 
I don’t want you to enjoy your vacations, but maybe you didn’t realize 
what all these extra days meant for me. It’s been a little hard.”
Therapist [after waiting to see whether she would continue]: How did 
that sound? Did you say what you wanted to say?
Martina: Let me try again. “Jamie, I didn’t resent your being away at 
first, but with all these extensions I felt a little— taken advantage of. 
I feel 
…
 like you haven’t really been paying attention to how I feel.”

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Therapist: How did that sound? How did that feel?
Martina: Better.
Therapist: How did you feel about your tone— did you come across 
the way you wanted to?
Martina: I don’t know, maybe it wasn’t strong enough.
Therapist: Let’s try it again
… 
.
After a time they reached a more comfortable role play, with Martina cau-
tiously showing more affect.
Therapist: So this is a great step. If you tell Jamie how you feel and 
she blows you off, it may mean you can’t trust her and that it makes 
sense to give up your friendship. On the other hand, if she hears you, 
and maybe apologizes, perhaps you can trust her and continue your 
friendship.
Martina: That makes sense.
There was no follow- up to this in the following session, in which Martina 
talked about her roommate and a minor incident with her family. The ther-
apist had been hoping Martina would confront Jamie, but recognized that 
things would happen at Martina’s pace. The next session:
Therapist: How have things been since we last met?
Martina: Actually, a little better.
Therapist: Good to hear. Did something happen that contributed to 
your feeling better?
Martina: Actually, yes. You know, we had talked about my talking 
to Jamie, who finally came back to work. I was nervous about 
doing it, and I actually wasn’t going to bring it up, but we got into a 
conversation about something else, and it happened.
Therapist: What happened?
Martina: Well, I felt a little annoyed with her not even mentioning my 
having covered her for so long, and I finally said something. It wasn’t 
exactly what we had rehearsed, but it was close enough. And— and 
I said, “I think maybe you owe me an apology.” Then I was really 
nervous, and she looked at me. But then she said, “You know, you’re 
right. I’m sorry. I guess I took advantage of your good nature.”
Therapist: Wow! How did you feel?
Martina: It felt great having taken the chance to say something, and 
especially that she heard me and acknowledged I was right. I felt 
better
… 
. I do feel like we can stay friends.

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Role Transitions 
85
Therapist: Great work! Brave of you to take the risk, and it sounds 
like it really paid off. So maybe you can trust your feelings, and even 
put them into words to see whether you can trust people in your life?
Martina: Maybe.
Martina seemed much less symptomatic and more open after this point. A ses-
sion or two later, she reported that her gynecologist had treated her brusquely 
during an examination in which she felt vulnerable and hurt. The doctor had 
explained his procedures, and Martina had not spoken up about how bad she 
felt— it was all an anxious, detached blur. In the session, the IPT therapist 
again validated her feelings of hurt and anger, explored potential responses, 
and role- played them with her. Martina reported that the next day she called 
up the doctor, arranged a follow- up appointment, and— somewhat to her own 
surprise, since she felt this was out of character— expressed her grievances. To 
her further surprise, the doctor apologized.
Therapist: How have things been since we last met?
Martina: Better, and let me tell you why!
Following this incident, symptoms further decreased, presumably reflecting 
Martina’s greater sense of agency and control over her environment. Based 
on these successes, she took further interpersonal risks; for example, tell-
ing family members more about how she had felt unsupported when she had 
previously spoken to them about her traumas. In each instance, thankfully, 
Martina received contrite responses from the other party she confronted. 
As a therapist, one hopes for such good outcomes. Her therapist had, how-
ever, reviewed contingencies with her in each case: “How will you handle it 
if they aren’t apologetic? What options do you have?”— and they had role- 
played these so that Martina would have been prepared had things not gone 
so smoothly.
Based on these successful encounters, Martina felt increasingly competent 
in social circumstances. She was struck by the sense that her feelings were 
just and meaningful, and that she could use them to assert herself with other 
people. She opened up to her roommate, turning a somewhat distant living 
situation into a friendship. By the end of treatment, she felt she was doing this 
better than she ever had before— even before the September 11
th
 trauma. Both 
PTSD and major depression resolved: her CAPS score had fallen to 17 and her 
Hamilton Depression Rating Scale score to 4. She applied for and was awaiting 
a promotion at work, resumed her writing, and rebuilt her social connections. 
She had tentatively resumed dating, and felt she was handling such dating 
better, as therapy ended.

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Termination, in sessions 12– 14, was “a mixed bag,” in her words. On one 
hand, Martina was flying high with a sense of new social competence. She was 
also literally flying: after having avoided airplanes since the September 11th 
trauma, she spontaneously took one to go on a vacation, mentioning the trip 
to the therapist only after having ticketed it. On the other hand, she initially 
worried that she was feeling depressed. On discussion, however, she and her 
therapist agreed that she was feeling 
sad
— without neurovegetative symptoms, 
guilt, or suicidal ideation— at the prospect of ending therapy. Her therapist 
normalized sadness as the emotion of parting and loss: normal, and not at 
all the same thing as depression, although the feelings can overlap. Martina 
baked a cake for her final session, and thanked her therapist for “practically 
saving my life.” At six months follow- up, she remained well, was in a relation-
ship, had gotten her promotion, and did not feel the need for further therapy.
Note how differently this IPT treatment evolved than would an exposure- 
based treatment. There was no discussion of the trauma after the initial ses-
sion, and only brief discussion then. There was no attempt to make Martina 
reconstruct the traumatic events and confront reminders that evoked them. 
Instead, IPT focused on helping Martina identify her feelings and use them 
in current interpersonal relationships. By gaining a greater sense of mastery 
of her inner emotions and outside relationships, and of the connection be-
tween them, Martina also managed to shed her re- experiencing, avoidance, 
and other symptoms of PTSD.
CASE E X AMPLE 2
Chuck, a 34- year- old married Catholic veteran engineer, presented with PTSD 
related to combat in the Middle East. His chief complaint was: “I haven’t gotten 
over Iraq, and my wife is driving me crazy.” On his second tour of duty, Chuck 
reported that his armored vehicle had hit an improvised explosive device 
(IED) in Fallujah, and that he had seen his company buddies and some “other 
people” (presumably civilians) die in Iraq. Although his physical injuries were 
minor, the war had taken a toll. An honorably discharged Marine, Chuck re-
ported experiencing flashbacks of explosions driving through the streets of 
New York. He awoke every night from horrible combat nightmares in which 
he was killing people or dying.
Life back home felt unreal; he felt numb, detached, and fearful; frightened 
of others. This included his wife, two young children, and relatives, who “can’t 
understand, don’t have a clue where I’ve been at.” He had trouble driving, 
always fearing an explosion on the road. He was angry at the way the ser-
vice had treated him and his comrades, how “the brass” and the politicians 
 
 

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had mishandled the war. He came to treatment at our hospital because he 
mistrusted the Veterans Administration. Chuck had a CAPS score of 85, in-
dicating extreme PTSD, and met