Improving Relationships in Trauma Victims: The Case for Interpersonal Psychotherapy and PTSD.

Cognitive-behavioral therapies (CBTs) emphasizing exposure have been the most widely studied and empirically validated psychotherapeutic treatments for posttraumatic stress disorder (PTSD). Prolonged exposure, which was recently endorsedby the InstituteofMedicine as theonlyPTSD therapy forwhich there is adequate evidenceof effectiveness, has a hypothesized mechanism of action consistent with the animal models of fear activation and extinction that form the basis for understanding PTSD from a neurobiological perspective.At the same time, it is known that interpersonal traumas are the most frequently occurring and potent precipitants of PTSD, that the avoidant and numbing symptoms of PTSD adversely affect one’s current relationships, and that social support reduces the risk of chronic PTSD after trauma. These facts suggest that for patients entering PTSD treatment, their current interpersonal relations are problematic and that improving themcould improve symptoms and overall functioning. Against this backdrop, Markowitz and colleagues (1) tested the efficacy of interpersonal psychotherapy (IPT)—an evidence-based, present-oriented psychotherapy with established efficacy for depression—for patients with PTSD. Based on Bowlby’s attachment theories (2), IPT initially focuses on helping patients understand their emotional responses as they arise in the context of their current relationships (“affective attunement”) and uses this understanding, along with behavioral methods such as problem solving and role playing, to improve and strengthen interpersonal relationships (3, 4). Current interpersonal problems are broadly defined as grief, disputes, life transitions,andinterpersonaldeficits.Byclarifying and resolving these problems in the here and now, symptoms may begin to improve, even if the origin of the symptoms lies in experiences in thepast.Thehighrateofcomorbiddepression in patients with PTSD provided an added rationale for exploring the efficacy of this treatment in PTSD. The three-arm randomized controlled trial compared IPT to both prolonged exposure, the gold standard for PTSD, and relaxation therapy, an active psychotherapy control that has known, but limited, anxiolytic effects. The authors hypothesized that both IPT and prolonged exposure would be superior to relaxation therapy and, more importantly, that IPT would be no more than “minimally inferior” to prolonged exposure. This last andmost crucial hypothesis wasmeant to demonstrate that IPT could serve as a viable alternative to prolonged exposure for PTSD patients who prefer an interpersonal approach. The study recruited 110 seriously ill patients with PTSD, 90% of whom had some kind of interpersonal trauma and many of whom had a history of multiple traumas (including childhood trauma in 36%). Over half had chronic PTSD, 50% had comorbid major depression, 50% had a comorbid axis II diagnosis, and most had limited social support (84% were single, and less than 50% were employed) and a history of unsuccessful community psychotherapy (75%) and pharmacotherapy (50%). Use of medication was not allowed, which may limit the generalizability of the study but may also have provided a more stringent test of the efficacy of the therapies. Therapies were delivered by experts over 14 weeks and were balanced for total therapy time and for therapist age and gender. Assessments used state-of-the-art instruments at baseline and at 7 and 14 weeks. The outcomes of the trial are potentially practice changing. Both IPT and prolonged exposure showed superiority to relaxation therapy on multiple PTSD, depression, and functional status outcome measures, and IPT was no more than minimally inferior to prolonged exposure, with a difference of 5.5 points on the Clinician-Administered PTSD Scale (CAPS), much smaller than the accepted 15-point CAPS difference required to demonstrate superiority between treatments. Only prolonged exposure was superior to relaxation therapy on the CAPS, with IPT showing an advantage that fell short of statistical significance (p,0.10), while only IPT was superior to relaxation therapy inmeeting thecriterion for response (a 30% reduction in PTSD symptoms) (response rates, 63% compared with 38%; prolongedexposure fell in between,with a response rate of 47%). Remission rates were relatively low and were similar in all three groups (26%, 23%, 22%). Both IPT and prolonged exposure were superior to relaxation therapy on the Posttraumatic Stress Scale–Self-Report, the Hamilton Depression Rating Scale, measures of quality of life and social functioning, and the Inventoryof InterpersonalProblems.The analysis indicated that the effects of prolonged exposure relative to IPT were greater at 7 weeks than at 14 weeks—that is, prolonged exposure appeared to be superior to IPT early on, This study reminds us that there may be multiple therapeutic routes to achieve the same beneficial outcome.