DISCUSSION

Allan received treatment in a research study in which his symptoms received serial assessment. We recommend this as part of any treatment. Primary outcome measures consisted of the CAPS (Blake et al., 1995) and the Ham-D (Hamilton, 1980). A CAPS of 39 or less is considered subthreshold (Blake et al., 1995), and we defined a priori a 30% symptom reduction as a treatment response. At termination, Allan’s CAPS and Hamilton scales had declined significantly; his CAPS score was 39, a 52% reduction, and his Ham-D score was 12, a 40% reduction, consistent with only mild depression. Thus he met criteria for treatment response, albeit not remission. Indeed, Allan’s PTSD symptoms had greatly diminished: he no longer suffered from nightmares, flashbacks, or affective numbing. Further, Allan no longer met criteria for borderline personality disorder. No longer anhedonic, he was re-engaging in interpersonal relationships and resuming a professional role. By the end of treatment, he was facing conflicts with friends more directly and contemplating confronting his parents and his aunt.

As acute IPT is a short-term treatment, patients will often leave therapy with interpersonal issues to continue working on. It is unrealistic to expect patients to resolve all interpersonal conflicts in fourteen weeks. Rather, the goal of IPT is to help the patient build a foundation for approaching interpersonal problems differently, a template that will continue to empower the patient over time and serve to prevent relapse. Although Allan would need to continue tackling these issues, his functioning at termination differed dramatically from before treatment, and the momentum the therapy generated left him highly motivated to continue such work. Despite major improvement by the end of therapy, he still met SCID DSM-IV criteria for mild PTSD (Spitzer et al., 1994). In particular, Allan continued to avoid the locale where the kidnapping had occurred, was unwilling to answer his phone, and still experienced mild hyperarousal symptoms. As testament to his ability to continue working on his problems after therapy concluded, however, at Allan’s three-month follow-up, his CAPS score was 14, an 80% reduction from baseline, and his Ham-D score was 2, a 90% reduction. Both of these are normative scores, and he no longer met criteria for an Axis I (or II) disorder. He had received no additional interval treatment.

Allan’s response to IPT treatment evokes observations of what worked and did not work during his course of treatment, as well as a discussion of how his case generalizes to the PTSD population. Like so many patients with PTSD, Allan entered treatment interpersonally mistrustful and affectively deadened. These two characteristic symptoms make IPT well suited for this population but also create unique challenges. Engaging the patient in the therapeutic relationship and identifying, normalizing, and actively encouraging the expression of affect are crucial components of successful IPT treatment. The patient with PTSD may meet this challenge with trepidation, but in our experience, this process is less aversive than the prospect of facing traumatic reminders in prolonged exposure.

Allan’s core difficulty with trust preceded his most recent trauma and may have resulted from childhood trauma. The kidnapping and his subsequent encounters with the legal and mental health systems reinforced and exacerbated this preexisting vulnerability. It is not unusual for patients with PTSD to present a proximate trauma and later reveal a longer pattern of victimization (Cloitre et al., 1997; Davidson et al., 1991). Although Allan desperately wanted to feel better, he began treatment not yet ready to open up and freely enter a collaborative relationship. We expect this reticence in PTSD, and find it important to help patients articulate these feelings and anticipate the process of treatment. The beginning phase of therapy necessarily focused on building a therapeutic alliance to help Allan to trust the therapist enough to take emotional and interpersonal risks.

Allan’s case illustrates the well-established connection between the quality of early attachments and the later development of psychiatric problems. Disruptions in early relationships with one’s caregiver, and childhood trauma in particular, leave individuals vulnerable to a host of later problems, including the development of anxiety disorders (Fonagy et al., 1996; Slade et al., 2005; Stovall-McClough & Cloitre, 2006). Allan’s mother did not protect him from his abusive stepfather. Besides exposing him to violence, she sent Allan the message that the abuse was his fault. From a very young age, Allan could not guarantee his safety. Combined with his mother’s dismissive style, these factors suggest that Allan did not develop a secure attachment to his parents. Rather, his adult stance of “not caring” and walking away rather than expressing his feelings may represent the adult outgrowth of an insecure, avoidant attachment style. We hypothesize that premorbid insecure attachment, a difficulty in establishing basic trust, leaves individuals with weaker support networks and limited ability to call on them in crisis. This makes them vulnerable to subsequent interpersonal disruptions after traumatic experiences, and hence to developing PTSD (Markowitz et al., 2009, p. 135).

As part of this research study, in collaboration with Kevin Meehan, Ph.D., we are measuring change in reflective functioning (RF). RF is the capacity to understand one’s own and others’ emotional mental states. The ability to reflect has been linked to attachment security and protects against developing psychiatric disorders (Fonagy et al., 1991, 1996, 2005). Allan’s ability to reflect on his and on others’ feelings was understandably quite constricted at the start of treatment. Allan’s early history had convinced him that the world is a dangerous place and women are disappointing. The kidnapping, with its interpersonal betrayal by the woman who set him up (and by the DA), brought these ideas into stark relief. Cloitre et al. (1997) note that “abuse which occurs during childhood profoundly interferes with the developmental tasks of that period, mainly self-other relatedness and self-integration” (p. 438). Although a young adult, Allan had not achieved a consolidated sense of self. This vulnerability compounded his difficulty with affect regulation. After the trauma, as any sense of safety he might have had unraveled, he retreated into avoidance. This was the only way he knew to protect himself from becoming overwhelmed by the anxiety, disappointment, and anger the trauma triggered. Working in treatment to verbalize his current experience, to make meaning of what happened to him, and to understand how his behavior affected other people, raised his RF from a very low 2.5 to a meaningfully improved 3.5 (of a possible 9), allowing him another, more effective mode of affect regulation.

Patients with PTSD not uncommonly present with comorbid Cluster B personality disorders, another well-established consequence of early attachment difficulties (Fonagy et al., 1995, 1996). Indeed, individuals with a personality disorder face a higher risk for developing PTSD (Axelrod et al., 2005; Golier et al., 2003), often have a more chronic, debilitating course of illness (Hembree et al., 2004; Southwick et al., 1993), and may have a higher risk for revictimization (Golier et al., 2003; Yen at al., 2002). Patients like Allan who carry a diagnosis of borderline personality disorder have demonstrated poorer response to prolonged exposure, which may even be contraindicated for certain patients who do not have the internal resources to handle it (Feeny et al., 2002; Lanius et al., 2010; Simon et al., 2002,). IPT for PTSD allows the therapist to address affective and interpersonal pathology more directly and may be a particularly good alternative for this group.

These common aspects of the PTSD diagnosis make IPT treatment for PTSD slightly different than for treating major depression. For both diagnoses, therapists need to help patients name affects, to understand them as interpersonal responses (e.g., anger) or symptoms (hopelessness), and to use this emotional understanding to respond to interpersonal encounters. In treating PTSD, the therapist can expect the patient to be emotionally distanced in a way depressed patients rarely are. The therapist needs to work even more than with a depressed patient to detoxify affects as powerful but not dangerous. The feel of IPT sessions with patients with PTSD— even those, like Allan, with comorbid major depressive disorder—differs considerably from those with major depression alone. Depressed patients may dislike their affects, but they usually cannot help but feel them. Patients with PTSD have walled off their feelings and are wary of removing the barrier.

The need to build a therapeutic alliance with an emotionally inchoate patient before tackling the interpersonal focus resembles the adaptation of IPT for borderline personality disorder; in treating comorbid PTSD and borderline personality disorder, familiarization with both manuals is helpful (Markowitz et al., 2007; for IPT for borderline personality disorder, see Chapter 11). Furthermore, while patients with PTSD may present with what appear to be characterological traits, it is important not to prejudge them as they often lift with treatment of the Axis I syndrome. Indeed, Allan met SCID II criteria for borderline personality disorder at study entry and no longer met criteria at study termination, suggesting that his presentation may have reflected his PTSD more than an underlying personality disorder. Regardless, with a patient like Allan, the IPT therapist may also need to work more concretely on rudimentary relationship and affect regulatory skills than would be necessary with a patient presenting with a simple depression or simple trauma.

Allan’s central difficulty with trust is typical of PTSD, and the beginning of treatment often felt like a concrete expression of his approach-avoid conflict. Allan created distance in the room with his sunglasses and “the face." On the other hand, he was sensitive to any interventions that felt “manualized" or impersonal, expressing his wish for and fear of attachment. Allan’s tendency to distance himself in his interpersonal relationships complicated creating the intimate, vital relationship essential to a successful treatment.

As with many emotionally detached patients with PTSD, it was not until therapy was half over that he had formed enough of an alliance that he could actively participate in usual aspects of IPT. Unsurprisingly, at his week seven assessments midway through treatment, his CAPS and Ham-D scores remained virtually unchanged from his baseline. Patients with PTSD avoid emotional exposure in the same way that they avoid situational exposure. Figuring out how to trust and how to express feelings were integral parts of the therapeutic process, and Allan’s ultimate success in establishing a working alliance was a tremendous therapeutic gain. IPT allowed Allan and his therapist to work at an affective level tolerable enough for him to stay in therapy without dropping out. In working with this population, one must be aware of this tension. Ideally, the therapist avoids both a distant, intellectualized treatment and overwhelming the patient with an intolerable level of intimacy and affective expression.

While IPT is an affect-focused treatment, the therapist must bear in mind the task in which he or she is asking the patient to engage. Many patients (particularly those with comorbid Axis II disorders) may develop PTSD because they lack the skills to experience strong emotions in a contained way. Allan demonstrated this difficulty as he began to directly experience his anger. Although his suppression of emotions clearly impaired many aspects of his life, it was familiar, and avoiding feelings caused little or no subjective distress—although he was quite anxious and depressed. As he began to experience anger, he felt flooded and overwhelmed. Role-playing in sessions became important to successfully working on this issue: practicing effective communication in the session modeled appropriate behavior and began to teach Allan rudimentary affect regulatory skills. This intervention is relevant for combat veterans, who often associate angry affect with violent acts. It is important to normalize emotion while simultaneously helping the patient to modulate its expression.

During role-play, Allan often directly challenged the therapist, using his at times acerbic wit and sarcasm to poke holes in her suggestions. At first, Allan’s attitude left her feeling frustrated, as Allan seemed more determined to prove her wrong than to solve the problem he had presented. As a beginning IPT therapist, it is easy to become mired in the patient’s reluctance to engage in role-playing. The exercise often requires significant redirection and discipline to help the patient focus. Over time, however, the therapist ultimately recognized the contradiction between Allan’s descriptions of himself outside of session and his behavior in session. In his outside relationships, Allan depicted himself as meek, unable to get anyone to hear his point of view. In session, Allan proved so sharp and articulate that the therapist often found herself tongue-tied. Pointing this out to Allan gave him concrete proof that he was capable of making himself heard; his self-perception was inaccurate. Role-play allowed Allan to learn from the therapist’s modeling and helped the therapist to fine-tune her interventions, as the role-playing revealed both Allan’s interpersonal limitations and his strengths. These practice exercises led him to take greater interpersonal risks outside sessions. A man with much to be angry about, he began to be able to express that anger more appropriately to others. Although Allan did not always achieve desired outcomes in his encounters, he successfully re-entered the interpersonal world, increasing his level of social support by re-engaging with his college roommate and attending social functions again. Mobilizing social supports is particularly important as termination approaches and the patient can no longer rely on the therapist.

During the second half of treatment, both patient and therapist began to feel time pressure. While at times they both felt that Allan needed more sessions to adequately complete the therapeutic process, the short-term model has distinct advantages for this population. For a patient like Allan with an avoidant style and (at least an apparent) Cluster B personality disorder, the prospect of an open-ended, long-term treatment might well have been intolerable. The boundary created by the finite number of sessions seemed to free him to open up more than he might have otherwise. Further, the intensity of short-term treatment makes it more difficult for patient and therapist to skirt primary issues: the time pressure increases the affective intensity of therapy. Finally, confronting termination in a structured setting facilitated Allan’s work on attachment and loss. Ultimately, termination empowered him, engendering a feeling of mastery: that in fact he could tolerate loss and disappointment and still lead a productive and satisfying life.

Allan’s presentation is fairly typical for patients with PTSD, although the diagnosis is a heterogeneous one. Affectively numb, these patients often withdraw from relationships either because they serve as reminders of trauma, or because they have lost interest due to detachment and a sense of foreshortened future. Like Allan, patients with PTSD frequently have trauma histories that predate the index trauma and may emerge over the course of treatment. Through treatment, Allan relocated his vitality—not an easy endeavor for him, as his greater range of emotional experience forced him to grapple with painful affects and ideas. However, this allowed him to reconnect with others, and to develop enough confidence in himself that he could embark on a career path and think about tackling longstanding issues with close family members. While Allan had not remitted at termination (and many patients with PTSD do not), he left feeling like more of a man. Communicating to Allan that he was capable of continuing the therapeutic work on his own, without the therapist’s support, was important in helping him to consolidate the gains he had made. Three months after treatment, he was no longer symptomatic and had remitted, having internalized the lessons learned during his therapy.

 
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