Sessions 1 to 3: Initial phase
Goals for these sessions included exploring in detail Mr. A.’s current and past relationships to understand his interpersonal functioning, to identify interpersonal issues linked to the onset of PTSD symptoms, and to take a trauma history. The therapist first explained the IPT approach to Mr. A. He acknowledged the prominent interpersonal difficulties in his current life and expressed his eagerness r to work on changing his behaviors. The therapist then reviewed Mr. A.’s current PTSD symptoms, which were based on the PSS-SR results. She observed that his avoidance symptoms were the most prominent. She took a general history of traumas throughout Mr. A.’s life. Mr. A. noted that each trauma involved a profound sense of betrayal, which led him to mistrust people and to avoid forming close relationships.
The most important people in Mr. A.’s life were his girlfriend Diane and his daughter Chloe. He felt that his traumas negatively affected both relationships. He was irritable with Diane, and he avoided close contact with Chloe to avoid being hurt. He cited similar problems in other relationships, and reported that the “major trauma” of his life, Chloe’s abduction, unquestionably exacerbated this distancing tendency.
Mr. A. often attempted to advise and guide others, considering that he related to others best by imparting knowledge. Unfortunately, his guidance was often unsolicited and not well accepted. This behavior also arose almost immediately in IPT sessions. Mr. A. elaborated in great detail how particular computer programs worked or what he had learned in a recent self-help class. He would talk without pause for several minutes, despite the therapist’s attempts to interject. This tactic succeeded in avoiding any guidance from the therapist.
A similar process unfolded with his daughter, who had recently expressed interest in studying law. Upon hearing this, Mr. A. began telling her all of the details of his custody battle with her mother, including an enormous number of personal and confidential documents. He deemed this a supportive act; she did not.
Mr. A. admitted that his concept of relationships and his approaches to others often left him feeling distant from the very people he cared for most. At times he felt “betrayed” after doing “so much.” For example, early in his relationship with Diane, her father developed a rare illness. Mr. A. immediately took it upon himself to research extensively alternative treatments. Mr. A. felt he was instrumental in saving her father’s life, but never felt recognized for it.
After Chole and Mr. A. were reunited, he was hurt by Chloe’s decision to live with her mother rather than with him. He also still grieved his lost bond with Chloe when she was a baby, a bond defining to him the purest and most powerful of connections. Although he admitted having struggled for many years with feeling comfortable in romantic relationships and with physical intimacy, he believed this struggle worsened after the abduction.
Mr. A. had trouble accepting affection from Diane. When they met they had sex regularly, but in recent years they stopped sleeping in the same bed and had only been intimate once in recent years. He summarized a recent, deliberate attempt to rekindle passion between them as “the attempt failed.” Diane frequently desired physical closeness, and although he cared for her and wanted to reciprocate the affection for her sake, he found himself recoiling from her touch. He described her as “coming at him” too fast with a hug or a kiss, and he experienced excruciating discomfort from any physical touch.
Just as Mr. A. sought solutions for his “PTSD,” he spent time seeking an explanation for his intimacy difficulties. He began questioning his sexuality, past and present. In his past, he had felt most comfortable with female bisexual partners, and was often told he “made love like a woman.” He felt an unusual bond in his recent online relationship with Jane, a male-to-female transsexual. Extremely attracted to her, he also felt he could be more open and honest online, whereas at home he had to feign interest and affection. He wondered whether this recent attraction stemmed from an online self-help course that encouraged attunement with both his “left” and “right” brain. Attraction to a transsexual, he opined, tapped into his “middle-brain.”
Mr. A. believed yoga, meditation, and spirituality helped him to feel more “balanced.” He stated his primary goal was to become more “disciplined” and “even tempered,” “like the Dalai Lama.” Nonetheless, he continued to struggle with self-regulation in interpersonal situations. His spiritual exercises, all solitary in nature, were not aiding his quest for equilibrium; on the contrary, they enabled Mr. A. to continue avoiding interpersonal contact and any strong emotions such exchanges might evoke.
Ipt Case Formulation
The IPT formulation concisely links symptoms to the focal interpersonal problem area. The formulation, presented as feedback at the end of the initial phase, draws on information gathered from the interpersonal inventory and provides an organizing focus for the remainder of therapy:
I understand from our initial meeting that your interpersonal goals are to be closer to Chloe and to reduce disputes with Diane. I also understand that you’ve always experienced interpersonal difficulties, but that they grew much worse after your daughter’s abduction-triggered PTSD. You have clearly worked hard over the years to overcome problems you’ve had in social arenas, and you’ve tried numerous times to address the painful memories of past traumas that still live with you today.
Your PTSD symptoms still overshadow your feelings and actions. You feel overwhelmed by both your emotions and your environment. Your symptoms are also coupled with an important current life issue you say has you’ve never discussed in past treatments: your sexual identity. Through understanding yourself in relationship to others, you cam mend your social conflicts and reduce your symptoms.
You’ve discussed how hard it is to trust people, and how that has limited your social network for years. Your wife’s abduction of Chloe took away the person closest in the world to you, and has made it extremely difficult—to this day—for you to trust others, to take the risk to connect with those around you. This mistrust is very common in PTSD. Avoidance, numbing, intrusive thoughts are all symptoms of the illness. Although you say that you always had difficulty in social situations, these symptoms are not necessarily part of your character; they’re indication of an illness that you suffer from—an illness that’s treatable and not your fault. The symptoms can improve.
Your mistrust has led you to minimize social contact. You’ve discussed feeling “betrayed” or “deceived” after trying to help others many times over.
So you’ve been keeping your distance through “electronic relationships” that are more comfortable. Yet, you say you “yearn for closer, more real relationships!”
You are going through a role transition: Uncomfortable feelings about your relationships and your own sexuality have made life extremely confusing, and it’s hard for you to know what you want from whom. What we can work on in the remaining weeks of treatment is how to navigate this transition: Do you want to stay with Diane, deepen a relationship with Jane, or what? If you can understand your feelings and use them to resolve this uncertainty, not only will your life feel better, but you symptoms are likely to subside. Does that make sense to you?
Mr. A. agreed to work on this interpersonal focus.
Session 4 to 10: Middle Phase
Having agreed to focus on his role transition, Mr. A. and the therapist entered the middle phase of IPT. Mr. A. now understood that he was suffering from a treatable illness that was not his fault, with clinical symptoms related to his past traumas. He would learn to detect and monitor these symptoms in the course of therapy, but should not blame himself for having symptoms or for their impact on his relationships. In all likelihood, he would start to feel better and see the symptoms subside.
In his role transition, Mr. A. was adjusting to changes in what and who attracted him sexually. The therapist introduced strategies to improve interpersonal communication, and helped elicit emotional responses that surfaced in the process. She supported Mr. A. in confronting and wrestling with intense (particularly negative) feelings. Mr. A. also needed to understand that his tendencies to intellectualize emotional experiences and to defend against any unpleasant moods complicated this shift. Tolerating his affects would help him become more connected with others and more open with his sexuality.
The therapist helped him to examine closely current conflicts and arguments. This would help Mr. A. determine what he wanted in these situations and explore interpersonal options, including role play to practice responses, to resolve them. Specific incidents from the week were reviewed, eliciting Mr. A.’s feelings and behaviors, and sessions offered a chance to practice and hone interpersonal skills.
“How have things been since we last met?”
This simple question starts every IPT session. It anchors both therapist and patient by focusing on current feelings and life events related to the focal problem area (role transition) and by eliciting current concrete interpersonal incidents on which to draw when discussing alternative interpersonal techniques (
Weissman et al., 2000). Mr. A. could seldom recall any events from his week to discuss and instead, chose to recount stories from his past. His week, after all, intentionally avoided interpersonal encounters; he thought there was little to recount. Alternatively, he would offer a detailed description of a computer program he was developing, dive into monologues about what it takes to be an effective software engineer, or return to his distant past. This parrying the opening IPT question was a fundamental challenge in the treatment.
The therapist persisted in probing each week, seeking to guide Mr. A. to the here and now and away from the distant stories indelibly fixed in his mind. Despite his cocoon-like existence, Mr. A. had interactions with others, though he may have wanted to avoid the affect attached to recent arguments with Diane, or an emotionally charged phone call with Chloe, or a negative response from an online communication.
Mr. A.’s communication style was intellectualized, emotionally detached, expressed in abstract theoretical rather than experiential verbiage. When asked a simple question like, “How did that make you feel?” he responded with an analysis of how his “left brain” was dictating his behavior, making it impossible for his creative, emotional “right brain” to respond. The therapist challenged him to explore the feelings he consistently ignored or avoided, using his vocabulary as an illustration. She suggested that such detached language contributed to his distancing himself from the real feelings situations evoked. She urged him to retell day-to-day encounters using emotional words and describing his momentary experience. Again, the focus was on everyday interactions rather than a review of his trauma experiences, which were in this case, too well rehearsed to evoke genuine emotion. The therapist would then return to the initial question: “How have things been since we last met?”
It was frustrating when, at first, Mr. A. couldn’t break old habits. The therapist felt as Chloe must have when she hoped for her father’s support but instead got a lecture, or Diane might have when trying to connect with him, only to be repeatedly rebuffed. Mr. A. clearly cared deeply about his relationships and suffered from his isolation, but he made it almost impossible to break through the veneer.
By Session 6, Mr. A. was better able to recount specific events from his week, and was willing to take greater emotional risks when feelings surfaced. He described a telephone conversation with Chloe in which they talked more openly about their current lives. He still wished he could have influenced her life decisions (e.g., career choice) and values. He also recognized that many of the feelings he often avoided or suppressed related to his daughter. His years of grieving about time lost with Chloe no longer mattered as much to him as did the importance of their current relationship. He then attributed his current qualms about having children with Diane to regrets and losses surrounding Chloe and to his generalized loss of trust in other people.
The therapist introduced role play for improving Mr. A.’s ability to communicate with his significant others. She encouraged him to limit his phone interactions and increase face-to-face meetings with his business partner. In such meetings, Mr. A. could break his isolation, better read facial and body cues, and circumvent conflict. The therapist clarified that this was not a form of exposure, rather a technique for relating to others better. Mr. A. was initially uncomfortable with this until they role-played scenarios in session.
The therapist encouraged Mr. A. to recognize when he was frustrated or angry with Diane and tell her. With practice, he gradually saw the benefit of this approach in preventing angry outbursts. Similarly, when Jane suddenly broke off on-line communication, the therapist encouraged Mr. A. to confront her rather than avoid the behavior’s meaning and the hurt feelings it evoked. The therapist validated and normalized these negative affects as useful indicators of social encounters.
The therapist used IPT’s medical model and designation of the “sick role” (
Weissman et al., 2000) throughout the middle phase to underscore that Mr. A.’s symptoms were not his personality or a personal failing. As Mr. A.’s PTSD symptoms had lingered for decades, he had, unsurprisingly, come to confuse the disorder with his character. He had internalized symptoms, such as avoidance, startle responses, and irritability, as if they were fixed traits he could only manage, not dissolve. With time, he began to recognize the symptoms were not his character and not his fault. Through understanding his emotions and
their role in daily minor encounters, he could reduce them so that he would merely experience healthy anxiety when reminded of traumas.
Just as Mr. A. had believed initially that PTSD an intractable part of himself, he also believed that strong feelings, such as anger or sorrow, could produce only negative outcomes. The therapist supported Mr. A. in confronting, rather than avoiding, intense (particularly negative) feelings. Each time he retreated into intellectualized language, she asked him to describe how he was feeling at that moment. Acknowledging, and simply sitting with an intense emotion, was his most challenging task.
This piece of the treatment was crucial, and is central to understanding how IPT differs from other affect-based therapies. Learning to acknowledge one’s emotions and to experience them more deeply is a shared core principle. However, in IPT the patient learns to understand a particular emotion as a response in an interpersonal context and then to communicate the feeling to improve an important relationship. Mr. A. did this with his irritability: his anger outbursts resulted from avoiding or suppressing intense feelings. If he could express his fears, anxiety, or disappointments with Diane as they surfaced, he was less likely to angrily “explode.” He practiced talking with Diane about his feelings when they were at peace, using “I” statements to avoid accusing or attacking language. He also shifted his communication of his feelings during sessions. Instead of “educating” the therapist, he now was willing to verbalize emotions and to explore their interpersonal context.
As the termination phase neared, an evaluator reassessed Mr. A.’s symptoms. His PSS-SR scores improved dramatically, falling from 25 at the start of treatment to 9 by session 8, indicating that he no longer met full criteria for PTSD. His BDI score remained euthymic, falling from 7 to 6.
Early in treatment, Mr. A. had responded hesitantly to techniques the therapist suggested, hiding behind intellectualization and refusing to focus on the present. He progressed as he became more willing to leave his comfort zone and to acknowledge that negative affects are not “bad,” but that sadness, loss, anger, are all useful, socially informative feelings if tolerated. This was a profound shift. He noticed he was becoming less irritable with Diane and his business partner and was less avoidant of social situations. He came to sessions more willing to discuss recent events and resultant feelings. He said this would never come easily or “naturally,” but he saw the benefit in trying. As a result, he felt better.
Session 11-14: Termination Phase
The final sessions reviewed the treatment course and addressed Mr. A.’s progress, his developing skills, and his feelings about ending therapy. The therapist acknowledged the sadness of separation, yet focused on the gains he had made, and reviewed areas where Mr. A. felt more competent and independent to function without therapy. Together they tried to anticipate difficulties that might resurface after treatment. Mr. A. recognized his progress, but voiced disappointment that treatment was ending and wanted to discuss ways to continue. He viewed “endings” negatively, recalling his childhood separation from his parents, his marriage, and his relationship with his daughter. He feared that parting would only bring gloom and helplessness, as it had in his past.
The therapist presented termination as a potentially corrective experience: Mr. A. could work through the feelings that arose in saying goodbye, and potentially, see that not only could he tolerate such emotions, but also that he deserved a sense of completion, mastery of skills, and progress.
At termination, Mr. A. was more socially engaged and communicated more effectively. He now considered his shift in sexuality more a curiosity than a bona fide change in identity, and decided his relationship with Diane was worth nurturing. He became more affectionate with Diane, talking with her more openly about both their future and his past. Diane knew about Chloe’s abduction, but not about the related traumas that contributed to Mr. A.’s fears of intimacy and lasting relationships. She also knew about his online relationship, but their discussions had never gotten past angry, jealous exchanges, so that she had been unaware of his longer standing sexual confusion. Mr. A. also reported that he felt his relationship with his daughter had improved. They talked more and she involved him more in her daily life.
In anticipating difficulties post treatment, Mr. A. expected his “poor people skills” would never remit, and he would need to continue practicing communication skills and challenging himself to approach people. He felt more capable of tolerating negative moods and better able to bounce back from conflicts. Mr. A. reported still thinking about past traumas and the people who had been disloyal to him over the years, but this occurred less often and less intensely.