Difficult Situations and Special Circumstances

This short eleventh chapter addresses problems that may arise in the course of treatment and therapist contingencies in responding to them. Topics include suicidality, dangerousness, violence, comorbidity, paranoid patients, revictimization, and patient discomfort in sessions. The question of abuse by a previous therapist receives discussion, as does the offer of telephone contacts by the therapist.

IPT for PTSD—Grief

Parallel to Chapter 7, this chapter describes how therapists treat patients with PTSD by focusing on complicated grief or bereavement, the traumatic death of a significant other. This is illustrated by a single but extended case example, including a description of the initial, middle, and termination phases.

IPT for PTSD—Role Transitions

This and the succeeding chapters focus on specific interpersonal problem areas, the focus of treatment for PTSD. This chapter provides a description of how therapists treat role transitions for patients with PTSD, the most common IPT focal area in PTSD. The chapter illustrates this in three extended case examples: Martina, Chuck, and Deborah. The chapter presents vignettes of therapist and patient interactions, including history-taking, formulation, proceedings from treatment sessions, and the termination of treatment. Each patient’s treatment scores are presented over time.

IPT for PTSD—Middle Phase

This chapter comprises a review of the middle sessions of IPT treatment for PTSD. This covers the interpersonal foci of grief (complicated bereavement), role disputes, and role transitions. It addresses techniques like affective attunement, eliciting, normalizing, validating, and helping patients verbalize feelings; eliciting a recent, affectively charged life event; exploring options; and role play. The key opening is a question: “How have things been since we last met?” Having identified a recent, affectively charged life event, the therapist uses an interrogatory triad to reconstruct it. Catchphrase: “Emotions are uncomfortable but not dangerous”—and indeed are even useful as social signals. The chapter also addresses thematic continuity of sessions and encouragement of taking social risks.

The Target Diagnosis

This chapter undertakes a review of the diagnosis of posttraumatic stress disorder (PTSD), as defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV and DSM5). It recounts the controversy over what constitutes a DSM Criterion A “trauma,” as opposed to other upsetting events. The chapter distinguishes between acute and chronic trauma, age of trauma, and other facets of traumatic events. It emphasizes interpersonal aspects of trauma. The chapter discusses the use of assessment instruments for serial measurement of PTSD and related symptoms. It further addresses the IPT characterization of PTSD as a treatable medical illness that is not the patient’s fault.

IPT for PTSD—Role Disputes

Comparable to Chapters 7 and 8, this chapter focuses on the IPT focal area of role disputes. It includes two extended case examples. Components of these cases include the initial, middle, and termination phases, and the use of techniques including history taking, formulation, affective attunement, role play, and the issue of transgressions.

Adapting IPT for PTSD

This chapter reviews adaptations we made to IPT in order to treat patients with chronic posttraumatic stress disorder (PTSD). In shifting from the standard model of IPT used for depression, changes included: (1) dealing with numbness through affective reattunement, (2) focusing on the interpersonal aftereffects of trauma rather than recounting traumatic events, (3) the deletion of the interpersonal focus of interpersonal deficits. Most aspects of IPT are retained, including mobilizing social supports, choosing an interpersonal focus, and the general structure of sessions and treatment. The chapter further provides an elaboration of attachment theory to explain why IPT might benefit patients with PTSD.

Is Exposure Therapy Necessary to Treat PTSD?

This chapter discusses the dominance of the exposure-based approach to therapy of PTSD, and of IPT as an alternative affect- and attachment-based, non-exposure approach. The chapter, based in part on published research articles, reviews prior research and recent findings from our randomized controlled treatment trial comparing exposure-focused Prolonged Exposure, IPT, and Relaxation Therapy for patients with chronic PTSD. Results showed that IPT was non-inferior to Prolonged Exposure and had advantages for patients with comorbid major depressive disorder—half the sample. Patients also preferred IPT to the other treatments, despite its having far less research support. Patients treated for 14 weeks with psychotherapy targeting PTSD were likely to lose the diagnosis of a personality disorder.

Practical Issues

This short summary, based on our original research manual, provides lists of therapist “Do’s and Don’ts.” Do’s include scheduling sessions, audiotaping or videotaping, giving the patient an IPT background handout, writing a progress note, and serially rating patients. Don’ts include encouraging patient exposure to trauma reminders and assigning homework. The best guide for this is supervision.

IPT for PTSD—Termination Phase and Maintenance

This chapter describes the closing phase of acute treatment and the possibility of ongoing further treatment using IPT for PTSD. Issues in termination include consolidation of gains, reinforcing social skills, building patient independence, emotionally acknowledging the end of treatment, and anticipating future problems. Maintenance IPT has demonstrated efficacy for mood disorders, but no data exist for PTSD, where we have only recently found evidence of acute efficacy.