Interpersonal Psychotherapy for Posttraumatic Stress Disorder

role dispute
. As your husband, Dave 
could be providing you important support in your life, but you seem to 
feel distanced, at odds with him. I suggest that we spend the remaining 
12 weeks of treatment focusing on your marriage, figuring out where 
you and Dave are having difficulty and how you can fix it. If we do 
this, there’s a good chance that you can improve the relationship, and 
your PTSD symptoms should follow. Does that make sense to you?
Alicia: Yes, that sounds like a plan. Although I doubt I can really 
change our marriage in that short a time.
A pattern developed in the early weeks of therapy. Alicia characteristically re-
sponded to the opening question (“How’ve things been since we last met?”) by 
describing an incident rather than a mood state. On exploring the incident, 
she would initially deny having any feelings, but on discussion acknowledged 
some, hesitantly at first. As this pattern continued, she became better able to 
name the feelings: “frustration” and “annoyance” became acceptably trans-
lated to “anger,” although she had initially dismissed that term as a character-
istic of her mother that she did not want to emulate.
Therapist: But everyone gets angry. It just means that someone’s 
bothering you or doing something you don’t like. It’s not a bad 
feeling, it just tells you about someone’s bad behavior. It’s normal to 
get angry; it is a social signal that tells you something important. If 
you ignore it, the problem is likely to persist. If you can find a way to 
express it more comfortably, perhaps it won’t build up into one of the 
explosions you’ve described.
The therapist continued to elicit and normalize her feelings, particularly 
the negative affects. Alicia said she was “allergic” to anger and sadness. She 

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joked that these were not “politically correct” emotions. But over time she in-
creasingly relaxed and accepted her feelings. As she remained very concerned 
about their expression— most concerned about expressing anger— she and the 
therapist role- played interactions. The IPT message is that emotions are useful 
social signals.
Session 5:
Alicia: So my aide hadn’t prepared the report I wanted, and I guess 
you’d want me to say I was annoyed.
Therapist: I’m not trying to manipulate you. What you feel is what 
you feel. How did you feel?
Alicia: I guess I was angry that she had two weeks to get a few 
pages ready and couldn’t do it. Did a terrible job. I’d never be that 
inefficient.
Therapist: Were there any extenuating circumstances? Did your aide 
have other pressures that might have distracted her?
Alicia: No, I made it clear this was the number one priority. And it 
isn’t the first time this has happened. She’s unreliable.
Therapist: And what’s your feeling, about her being unreliable?
Alicia: Annoy— well, anger.
Therapist: And is it reasonable to feel angry if she’s unreliable with an 
important assignment?
Alicia: Yes, I think so. Although you know I don’t like that.
Therapist: How have you handled that with Sally [the aide] in 
the past?
Alicia: I’ve just let it go. [Pause]
Therapist: Oh?
Alicia: Well, you know. I don’t like confrontations.
Therapist: So are you angry not only about this report, but about past 
things you’ve asked her to do?
Alicia: Yes.
Therapist: Think it’s reasonable to be a little angry at this point?
Alicia: Yes, although it’s not my thing.
Therapist: So what can you do?
Alicia: I could not entrust her with priorities anymore. Or I guess 
I could tell her I don’t need her services.
Therapist: Yes, those are options. Is she just not worth keeping 
on staff?
Alicia: [Reflecting] Sally does have some good qualities, just maybe 
not with time management and thoroughness. She has good ideas, 
like in my last campaign. She can be compassionate.

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Role Disputes 
113
Therapist: So before you give up or fire her, is there something else 
you could do?
Alicia: Like what?
Therapist: What are your options?
Alicia: I guess I could say something
… 
.
This dialogue led to a productive series of role plays in which Alicia tried 
saying different things, ranging between too indirect and too confrontational 
(“Where was that page I was looking for?” vs. “I’m sick of your not getting  
anything done!”); in question form at first (“Sally, where was that page?”); 
later, with therapist encouragement (“I notice you’re asking her a question. 
Is it a question, or is there a declarative statement you’d like to make?”), as a  
declarative statement (“I need to talk to you about how I’m feeling about 
things. I feel like I give you important things to do because I rely on you, and 
then you let me down.”) They also discussed and practiced modulating her 
tone of voice, so that it was neither too weak nor too strong.
This discussion in the sessions addressed a difficult relationship outside the 
home rather than the marital dispute on which the treatment had generally 
focused. Nonetheless, once Alicia had brought up her problem with Sally, it 
seemed to the therapist an important parallel instance in which Alicia could 
understand her feelings and modulate their expression in a constructive way. 
Working with this material validated Alicia’s raising it in session, and cer-
tainly maintained the same theme of her irritation in interpersonal disputes. 
Focusing on work also seemed to be a “safer” place for Alicia to test her feelings 
than in the more charged atmosphere of her marriage. This had not been part 
of the therapist’s plan, but appeared a reasonable adjustment in the face of the 
patient’s presentation of material.
Session 7 began with the therapist asking, “How have things been since we 
last met?” Alicia, looking brighter and calmer, responded that she had set up a 
time to talk with Sally and had talked to her, reasonably calmly and assertively. 
Sally had made excuses, then burst into tears and apologized, saying she how 
much she admired Alicia and wanted to help her work. Alicia reported that she 
had felt a little frightened by Sally’s crying, but had felt gratified by the way the 
encounter proceeded. Moreover, Sally had since been more efficient and reli-
able. The therapist explored how Alicia had felt during the encounter.
Alicia: Nervous at first, then really relieved, and really good. By the 
time we stopped and she went back to her desk, I felt much more in 
control of the situation.
Therapist: That’s great! And how’ve you been feeling since?
Alicia: A lot better, more relaxed. Though it took something out of me.

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Therapist: That’s wonderful. So this is what we’ve been talking 
about: you risked bringing up your feelings, Sally was able to hear 
them, and the relationship between you feels better. And you feel 
better.
Alicia: Yes, it’s true.
Therapist: Terrific! And if you can do that with Sally, perhaps the 
same approach will also work with Dave?
Alicia: Dave? Yes, it’s worth a try.
Thus emboldened (if still cautious), Alicia talked more about tensions in 
their relationship. She felt unsupported and rejected by Dave— now that she 
thought about it, angry at him. Although they maintained a façade of nor-
malcy in public and with their children, they barely spoke and had little phys-
ical contact.
Alicia: I’m hurt and angry. He doesn’t seem to care about me; he just 
goes through the motions.
Therapist: Does he know you feel that way?
Alicia: Of course.
Therapist: You’ve told him?
Alicia: Not in so many words. But he must know from the way 
I behave toward him. He must sense it from the way I look at him 
at times.
Therapist: How is that?
Alicia: I don’t know. He should just see it.
Therapist: How would you like him to show that he cares?
Alicia: I’d like him to take me in his arms and tell me so. But that’s not 
his style, at least not these days.
Therapist: You’d like him to hold you and tell you.
Alicia: Yes. Yes!
Therapist: Are those reasonable feelings for you to have?
Alicia: Yes, I think so.
Therapist: Okay. I think so, too. Are you sure he knows that you want 
him to behave like that?
Alicia: He should. He has to.
Therapist: What options do you have to let him know?
Alicia: I guess, like with Sally, I could tell him. But I shouldn’t have to.
Therapist: It would be nicer if he could do it spontaneously. But from 
what you’ve said, it’s been a while. So how might you communicate 
what you’d like?

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Role Disputes 
115
Alicia: I could say— Dave, I need to talk to you about how I’m feeling 
about things 
…
 [tails off]
Therapist: [Waiting a beat.] Uh- huh?
Alicia: I feel like we’ve been having problems in our marriage, and 
I want it to get better. I feel hurt and frustrated by the distance 
between us. It’s probably my fault, and I know you think I’m an 
empty politico, but
…
.
Therapist: Yes?
Alicia: I love you, and I want you to take me in your arms and tell me 
you care. — Oh, that sounds so corny!
Therapist: You think so? I thought that was really sincere and caring. 
But how would you want to change that?
They tried a few other approaches.
Session 8 brought no real developments. Alicia had thought about talking to 
her husband, but hadn’t gotten around to it— she conceded she was frightened. 
She and her therapist spent the session exploring her feelings and doing more 
role plays, including playing out contingencies: how could she handle things 
if Dave avoided a conversation, or dismissed her, or got annoyed? They ended 
up talking about “going through the 
e
motions” in the marriage as opposed to 
“going through the motions.”
Session 9, for which the therapist had had high hopes of Alicia confront-
ing Dave with her feelings, again passed relatively uneventfully. Alicia talked 
about her office, where Sally was doing a better job, and about her relation-
ships with her children, which also seemed to be deepening and improving. 
She and Dave had not had sex in a few months, though, and she expressed 
frustration about that. Her therapist asked: “What options do you have to deal 
with that?”
Session 10:
Alicia: You always ask me, “How have things been since we last met?” 
I’m going to beat you to the punch. Things have been, as you would 
say, really interesting. I took the plunge and talked to him— and it 
went well!
Therapist: Great! Tell me!
Alicia: Well, I told him at dinner that we needed to talk that night, and 
he looked puzzled, a little nervous, but he said okay. So after we got 
the girls put down for the night, I opened a bottle of white wine and 
we talked. I tried the lines we’d practiced, and it wasn’t completely 
smooth, but it was pretty good. I told him I loved him and felt hurt 

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and frustrated and all that. That I felt he had given up on me, even 
on making love, and that it was really frustrating. And when I got to 
the part about wanting him to hold me— he did! And we made love 
for the first time in forever, and it felt a little awkward at first, but 
then much closer than maybe it ever had. I was nervous, but I also 
feel more like I can trust him. It’s like everything we’ve been talking 
about all this time came together at once.
Therapist: Amazing. You did a great job! How are you feeling?
Alicia: I feel so much better. The next morning I was a little worried, 
like would it last? And that night, I got nervous, because Dave said