Interpersonal Psychotherapy for Posttraumatic Stress Disorder

Suicide.
 Patients with PTSD, especially those with comorbid depression, carry 
the risk of clinical worsening and, as a worst outcome, suicide. Many have at 
least passive suicidal ideation, the feeling that life is too painful and not, or 
barely, worth living. None of the 14 patients in our open pilot trial (Bleiberg 
and Markowitz, 2005) and one of the 40 IPT patients in our randomized trial 
(Markowitz et  al., 2015)  attempted suicide. Suicidal ideation needs careful 
exploration, beginning with intake into treatment, to determine level of 
risk: Has the patient made previous attempts? Has he or she developed a plan for 
self- harm? Written a will? In our research, we asked therapists and evaluators 
to stay alert to suicide risk, assessed it on rating scales, asked treatment staff to 
 
 
 
 

---

Difficult Situations and Special Circumstances 
131
report any meaningful suicide risk immediately, and subsequently discussed 
cases in supervision. The rare patients who reported worsening of suicidal 
ideation received additional assessments to ensure their safety.
Patients tend to feel suicidal because their level of distress feels unbearable 
and because they can foresee no future relief of this pain. The IPT approach to 
suicide includes:
 •  Recognizing suicidality as a treatable symptom of PTSD (and 
depression) that it’s crucial for the patient to survive; once the patient 
feels better, suicidality is likely to fade
 •  Providing therapist availability
 •  Monitoring rather than avoiding the issue
 •  Maximizing safety
A therapist might say: “I know you’re in a lot of pain, and that you don’t see any 
way out. But you have an excellent chance of getting better, of beating PTSD, 
even if it’s hard for you to see it right now. And 
when you’re feeling better, you’ll 
want to live. It’s important for you to stay alive long enough to get better
.” The 
therapist should explore contingency plans: what to do if the patient feels more 
out of control and seems likely to harm him-  or herself. This might include 
social supports the patient can contact to talk about these painful feelings, and 
the therapist should make him-  or herself available if the patient needs addi-
tional time and contact. It’s important to remind patients that it’s far prefer-
able to go to an emergency room if necessary than to attempt suicide.
If the patient has a suicidal plan, it is important to try to remove access to 
self- destructive means: throwing out a cache of pills, with family supervision; 
removing firearms from a house, etc.
Once suicide risk has been assessed, it should be labeled a psychiatric 
symptom that is likely to improve as the patient’s syndrome remits. The med-
ical model of IPT is a useful explanation here, and the therapist’s warm sup-
port and caring stance (again: “You need to stay in one piece long enough to 
get better; then you won’t want to hurt yourself”) should be protective to most 
patients. New onset or worsening of suicidal ideation should be examined in 
an interpersonal context: has something happened recently that has provoked 
greater dysphoria and suicidal symptoms?
In a research study, suicide risk triggers more frequent monitoring of symp-
toms. A patient with worsening suicidal risk might be withdrawn from the 
formal treatment protocol in order to receive additional treatment. Study 
therapy could then continue (the therapist shouldn’t abandon the patient in 
a crisis) but be augmented by psychotropic medication, couples therapy, or 
whatever other interventions might be appropriate. In clinical practice, the 

---

132 
I P T   F O R   P T S D
goal is not to test the efficacy of IPT but to ensure that the patient gets better, 
rather than dying. Hence, therapists should not fear adding interventions, a 
“full court press” of psychiatric treatment, if necessary.
The only caveat is that a therapist should recognize suicidality as part of 
the range of psychopathology and need not abandon monotherapy with IPT 
simply because the patient reports it. A therapist who flinches prematurely, 
appearing panicked by patient symptoms, is not likely to imbue confidence in 
the patient. Thus therapeutic poise (Greenacre, 1957) and clinical judgment 
are important in deciding if and when to alter the treatment regimen. Mixing 
therapeutic elements into an eclectic slurry may actually confuse and dis-
courage patients by blurring the thematic approach (Markowitz and Milrod, 
2015; see Chapter 12).
In clinical practice, IPT is supportive, encouraging, and efficacious. These 
factors probably play an important role in averting suicide attempts and com-
pletion in at- risk patients. Blaming the disorder (PTSD or major depression) 
rather than the patient, recognizing the patient’s suffering while emanating a 
concerned but calm, clinically optimistic but realistic, outlook (there is hope!), 
and providing encouragement and support are powerful therapeutic tools.