In the Aftermath of the Pandemic: Interpersonal Psychotherapy for Anxiety, Depression, and PTSD

John Markowitz’s appropriately titled volume, In the Aftermath of the Pandemic: Interpersonal Psychotherapy for Anxiety, Depression, and PTSD, provides therapists with a primer for conducting psychotherapy with individuals experiencing COVID-19–related distress. The book specifically focuses on the application of interpersonal psychotherapy (IPT) to the treatment of psychiatric disorders associated with pandemic-related life events. Although Dr. Markowitz explicitly advises against eclectic psychotherapies (“Patients will be less likely to leave with a clear game plan for the future if the therapy itself has been unclear or too complicated. So pick one therapy and stick to it.”), many techniques and principles discussed in the book could be applied in other, non-IPT settings. Thus, the book will be of primary interest to IPT therapists, but it may also appeal to anyone seeking guidance on conducting psychotherapy for pandemic-related distress.

Written in mid-2020, Dr. Markowitz’s descriptions of the horrors that befell New York City at the start of the pandemic serve as vivid reminders of an especially difficult time in the United States, and, indeed, the world. Hellish depictions of bodies piling up outside of morgues, inadequate personal protective equipment, and tales of physician suicide are both painful to read and somewhat dated (at least in countries where vaccines are readily available). But most of the book’s content remains surprisingly (and distressingly) relevant in late 2021. This continued relevance speaks to both the devious transmutability of the SARS-CoV-2 virus and the enduring impact of social changes related to the COVID-19 pandemic. I expect the book will continue to remain relevant beyond the current pandemic because future pandemics, alas, are sure to follow.

Dr. Markowitz, an expert in PTSD, writes through the lens of a trauma researcher. He draws parallels between the COVID-19 pandemic and other natural disasters, highlighting research showing that worse psychiatric outcomes are associated with traumatic events with a long duration, such as this pandemic. He identifies clinical characteristics that may help predict who will develop poor psychiatric functioning after trauma, including prior traumatic experiences, limited social supports, and insecure attachments. The scope of the book is expansive, including applications of IPT for treating pandemic-related anxiety disorders and depression, in addition to PTSD. Fortunately, Dr. Markowitz is also an expert in these disorders, so the book is extremely informative across topics, despite the breadth of subjects covered.

The first part of the book (introduction, chapter 1) catalogues key losses associated with the pandemic, resultant social threats, and psychiatric consequences. It lays the groundwork for understanding the relationship between traumatic events and psychopathology: the pandemic causes social stresses, including loss of regular routines, social isolation related to social distancing, and shock after the profound loss of human life caused by COVID-19. These stressors, in turn, are associated with psychopathology, most commonly depression, anxiety, PTSD, and substance misuse. IPT, a therapy that works at the interface of life events and psychiatric symptoms, is put forward as an excellent candidate for addressing psychiatric disorders arising in the context of a disaster.

Chapter 2 focuses on telepsychotherapy. Almost all therapists pivoted rapidly at the beginning of the pandemic to provision of psychotherapy by video, with little guidance on how best to manage these sessions. This excellent chapter provides both a review of the extant literature about teletherapy (not much is known) and helpful tips for setting up and conducting remote psychotherapy sessions. Dr. Markowitz notes that much of the material contained in this chapter is adapted from an article published elsewhere (1).

Chapters 3 and 4 introduce the reader to IPT concepts. They provide a nice refresher for those already familiar with IPT but likely would not suffice to teach IPT to a novice. In these chapters, Dr. Markowitz argues that IPT is especially well suited among the evidence-based therapies to addressing the social and interpersonal challenges generated by COVID-19, because it focuses on the connection between mood and life events. He notes that cognitive-behavioral therapy (another evidence-based therapy) “benefits from the disparity between a relatively benign life situation and catastrophic thinking, [whereas] IPT works best in the setting of actual trouble.” The COVID-19 pandemic, of course, qualifies as “actual trouble.” Dr. Markowitz points out that the IPT framework works well for pandemic-related problems because many of the common issues raised by the disaster fit well with the main IPT problem areas, such as grief (e.g., death of a loved one from COVID-19), role disputes (e.g., marital troubles arising when lockdown forces close quarters and increased demands on families), and role transition (e.g., the large-scale upheaval in social roles related to the pandemic, including homeschooling, job loss, and social isolation). Chapters 5–7 discuss the common psychiatric disorders seen in the wake of COVID-19 (major depression, PTSD, and anxiety), providing suggestions for addressing each of these disorders using the IPT framework. Each chapter includes clinically relevant case vignettes to illustrate use of the interpersonal problem areas in the context of pandemic-related life events.

The author describes and provides a template for the COVID Behavioral Checklist. This very brief measure systematically assesses the impact of COVID-19 on four key domains: worry about infection, daily routines, social contacts, and time on social media. Each clinical vignette includes the patient’s responses to the COVID Behavioral Checklist, demonstrating how this brief inventory can be extremely helpful in understanding individuals’ responses to the pandemic. This little gem is worth the price of the book; it is relevant to any patient affected by the COVID-19 pandemic (which, as of this writing, is almost everyone) and can help clarify salient issues for psychotherapy.

Chapter 8 focuses on termination, reminding readers that IPT is time limited and that most patients, even during the pandemic, fare well with a relatively brief intervention. As in standard IPT, therapists are encouraged to review treatment gains, assess nonresponse, and plan for future episodes. This chapter provides insight on when to offer maintenance sessions or continuation treatment, citing studies of IPT for depression that have shown benefit for these longer-term formats. The book ends with a discussion of resilience and the potential for posttraumatic growth (i.e., positive psychological outcome in response to trauma) after therapy. This mostly upbeat ending is tempered with a cautionary note about the need for more studies to better understand optimal therapeutic approaches for individuals with psychological distress in the context of the pandemic.

Written by an internationally recognized expert in IPT, trauma, and depression, this relatively short book is filled with clinically useful tips, excellent vignettes, and jaunty prose. The content is especially informative for those who wish to apply IPT to psychiatric disorders emerging in the context of pandemic-related life events, but even non–IPT-trained therapists will discover useful ideas for helping their patients manage the psychosocial sequelae of COVID-19.

Although we all wish that the pandemic was behind us, it remains an unfortunately potent physiologic and psychological force in our lives today. Dr. Markowitz’s book therefore is a timely and welcome guide to addressing with psychotherapy the most common psychiatric disorders emerging in the wake of the pandemic. For better or for worse, it is likely to remain relevant and useful for many years to come.