At the time of treatment, Allan had no known current or history of significant medical illness.
A diminutive young man, appearing his stated age, Allan presented at his first session wearing large, dark aviator sunglasses. He was guarded, his affect was constricted, and he described his mood as “dead." Allan’s speech was within normal limits and his thought process was goal-directed. He appeared alert and oriented. His insight appeared fair and his judgment appeared adequate.
In reporting his symptoms, Allan was barely audible, and the therapist had to work hard to elicit his narrative. She introduced the concept of IPT and gave a rationale for his symptoms: Allan had suffered a severe trauma, and his nightmares, distrust, and avoidance were all part of PTSD, a treatable medical illness. He responded to this intervention with a raised eyebrow and a shrug of his shoulders. Allan stated he was not convinced but was willing to give this therapy a try because “I have no other options."
In the initial phase of therapy, the therapist conducted an interpersonal inventory to assess Allan’s current social functioning, social supports, and the impact of the trauma on his relationships. Allan stated that he had no close friends. He reported having acquaintances that he saw at parties but could not name specific, meaningful relationships. Allan reported that even these relationships had become more distant following the kidnapping, but denied having had close friendships before the trauma. Allan reported one romantic relationship that had lasted a year; although the relationship had ended several years before, he still had strong feelings for this woman and had not recovered from the breakup.
At the time Allan began treatment, his most frequent social contact was his aunt. Allan reported that she was the one person in his life who had cared about him and proven herself trustworthy. However, she was in the midst of her own crisis, grieving the recent loss of her son. Allan reported that his aunt also had nightmares and often woke him in the middle of the night with her screams. Like Allan, his aunt spent her days locked in their small apartment, where she cried for hours, praying to be taken to join her son in heaven. Allan recognized that his constant exposure to his aunt’s distress exacerbated his symptoms. However, he did not believe it would be worthwhile to speak with her about her behavior, nor was it his style to say anything.
He did not want to compound her burden and doubted she would understand what he was going through.
Allan reported a “disappointing” relationship with his mother, and that the kidnapping brought up his angry feelings about her behavior during his childhood. Recently he had tried to confront her about her refusal to protect him from his stepfather’s abuse. She responded dismissively: “I’m sorry you felt that way.” Although Allan reported he currently “felt nothing” towards her, he described this conversation with barely contained rage. To Allan, his mother’s statement meant that she both minimized his suffering and denied responsibility for her mistakes as a mother. “Whatever; I don’t care,” he said with a sigh. As Allan’s emotions had been so frequently discounted or ignored, validating his feelings would become a very important part of his therapist’s role.
Describing his relationship with his father, Allan stated proudly: “We are exactly the same person.” Although he did not see his father often as a child, he felt much more connected to him as an adult. Allan described feeling tremendous anxiety, however, about his father’s reaction to his kidnapping. Despite Allan’s insistence that his attorney father stay out of the court case, the father tried to pull strings regarding the investigation. He called Allan weak and foolish for not wanting to testify. Again, Allan denied feeling angry, but his tone of voice became heated and loud in relating this story.
By the third session, the therapist helped Allan select the IPT focus of role transition, presenting a formulation for his current symptoms. While the loss of Allan’s cousin led the therapist to consider grief as a potential problem area, the role transition focus seemed most appropriate to helping Allan process and recover from the many life changes that had occurred as a result of his trauma. Not only had Allan suffered a terrible trauma, but as a result, he had left his job and begun avoiding his former life. Furthermore, Allan was multiply traumatized, and this most recent event reactivated unresolved feelings about his early abuse. Besides focusing on the symptoms of PTSD, IPT would necessarily address the interpersonal and occupational consequences of his response to his current and earlier traumas. In just three sessions, Allan had already described feeling powerless in multiple situations—during the kidnapping, with the DA, and in his relationship with his mother. This sense of helpless inefficacy seemed to fuel Allan’s PTSD symptoms. In addition, his chronic distrust, likely linked to his previous trauma history, was creating significant barriers to his becoming intimate with others and engaged in his life.
In the formulation, the therapist stated, “You are going through what we call a role transition—in thinking about the kidnapping, there is a before and after. You are transitioning from how things were before to a new role where you have to rebuild your relationships, get through this court case, and find a new job. part of helping you to feel better will mean understanding all of the ways that your life has changed and figuring out how to adjust to your life now. Feeling like you can’t trust people is a symptom of PTSD. You had experiences when you were young with your mom and stepfather—anyone who was in that situation would feel less trusting as a result. And then we have what happened to you now, which added on top of that. We can expect that this will also affect your ability to trust me. But this is something that we can work on, and we can also figure out where you want to go from here. We can talk about what you would like to get out of what you’ve gone through and what you would like to happen next.”
Though the IPT formulation is meant to reassure and to provide an organizing framework for the treatment, Allan responded with his characteristic interpretation of the interpersonal world around him. “I’m just another case that you’re fitting into a manual for your research,” he lamented. “This isn’t about whether I get better, it’s about whether or not you prove your research” At this point, it was important for the therapist to tolerate her own frustration and avoid becoming defensive; Allan could not openly accept the formulation because it would mean allowing himself to feel hopeful and vulnerable. Attacking the manual was a manifestation of his distrust and disengagement. The therapist explained that the point of the treatment was to understand his individual experience, to help Allan with his unique set of vulnerabilities and possibilities. She again underscored and empathized with his pervasive feelings of distrust. But the sunglasses stayed on throughout these early sessions. While Allan’s skepticism and distancing behavior made the initial sessions more challenging, the therapist also saw how vulnerable he felt, and how desperately he was clinging to these protective maneuvers. Many patients with PTSD are characteristically closed off in early sessions and, like Allan, so disconnected from their emotions that they are unsure of and confused by what they feel. Therapists can anticipate this and also predict an efflorescence of emotion as treatment progresses.
Thus the beginnings of the sessions in this early phase of treatment were stilted, with Allan’s brief recounting of the week’s events (in answer to, “How have things been since we last met?”) punctuated by long silences and a vacant expression. The content of the sessions remained sparse, as Allan’s internal emptiness was mirrored by his lack of activity and engagement in his day-to-day life. Although staying inside and “doing nothing” was meant to protect Allan from perceived intruders, the therapist worked to help him realize that this strategy was worsening his symptoms. Getting better would involve taking a more active life role. The therapist encouraged Allan to reach out to the friends and acquaintances that he had been ignoring, emphasizing the benefits of social support. Though not overtly rejecting these suggestions, Allan often seemed miffed and irritated by the therapist. The therapist began to feel hapless, perhaps responding to Allan’s internal feelings of inefficacy. By pointing out his irritation, however, the therapist made space for Allan to acknowledge what was upsetting him. Allan said he found frustrating the therapist’s opening question, “How have things been since we last met?” He grumbled, “You ask me the same question every time, and it makes me want to say nothing” Like the other important figures in Allan’s life, by Session 5, the therapist had already disappointed him. The therapist responded to his frustration by encouraging Allan to consider how he would like to begin the sessions. She also explained the rationale for the opening question, attempting to model flexibility while simultaneously retaining the function of the opening question. Although in ways it seemed that Allan was repeating an interpersonal pattern with his therapist, he was also trying something different. Typically, Allan walked away from conflict or threw up his hands in surrender the minute he became frustrated. Here he was testing the therapist, gauging whether she would let him down as everyone else had or might somehow rise to his challenge. His eyes peered over slightly lowered shades.
Allan arrived for Session 6 without his sunglasses, although without this concrete protection, his stony facial expression further hardened. Yet Allan took the therapist’s explanation of the opening line to heart (and the therapist took his complaint seriously by staying silent rather than asking the usual opening question).
Rather than shutting down at the beginning of session, Allan spontaneously began describing examples of interpersonal situations that bothered him during the week: As a favor, Allan had taken his young cousin and her visiting friend on a tour of New York City nightlife. He took them to an arcade and sat at the table while the two girls played games that he paid for. “It was boring, I felt like a chaperone,” he stated, exasperated. Exploring this situation, the therapist questioned why he agreed to a plan that did not interest him, and why he decided not to participate once he had agreed. Allan answered that he preferred not to get emotionally involved. He had decided it was best not to care about anything. He stated matter-of-factly, “If I don’t care, I can’t get hurt” While Allan felt protected by this attitude, the therapist encouraged him to consider the negative impact of “not caring” Allan recognized that his cousin and her friend ended up thinking he “was an asshole. They didn’t think I liked them” Despite setting out to do something nice for them, he ended up alienating them. “I just give them ‘the face,’ and I don’t know why” Together, Allan and his therapist realized that “the face” was the equivalent of his dark sunglasses. His opaque expression was meant to keep his feelings of vulnerability and anger private and concealed.
The therapist observed that Allan had given her “the face” in sessions when frustrated with her opening question. She pointed out that once Allan articulated his frustration, they were able to work together to resolve this conflict. Until then, it had been clear something was bothering him, but it was impossible for the therapist to read his mind or to rectify the situation. She suggested that this style of communication might partially explain why he so often felt disappointed by others. After recognizing how this pattern occurred in session, Allan was able to more fully acknowledge his role in the encounter with his cousin. Rather than feeling like a victim, Allan began to consider that by changing his behavior, he might be able to influence his environment and his relationships. The session then emphasized helping him to consider options for expressing his feelings to her and role-playing alternative conversations.