Essay Grade

Professional Psychology: Research and Practice
2011, Vol. 42, No. 1, 8 –15
© 2011 American Psychological Association
0735-7028/11/$12.00 DOI: 10.1037/a0022351
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
A Clinician’s Guide to PTSD Treatments for Returning Veterans
Brian A. Sharpless
Jacques P. Barber
Pennsylvania State University
University of Pennsylvania and Philadelphia VA Medical
Center, Philadelphia, Pennsylvania
What options are available to mental health providers helping clients with posttraumatic stress disorder
(PTSD)? In this paper we review many of the current pharmacological and psychological interventions
available to help prevent and treat PTSD with an emphasis on combat-related traumas and veteran populations.
There is strong evidence supporting the use of several therapies including prolonged exposure (PE), eye
movement desensitization and reprocessing (EMDR), and cognitive processing therapies (CPT), with PE
possessing the most empirical evidence in favor of its efficacy. There have been relatively fewer studies of
nonexposure based modalities (e.g., psychodynamic, interpersonal, and dialectical behavior therapy perspectives), but there is no evidence that these treatments are less effective. Pharmacotherapy is promising
(especially paroxetine, sertraline, and venlafaxine), but more research comparing the relative merits of
medication vs. psychotherapy and the efficacy of combined treatments is needed. Given the recent influx of
combat-related traumas due to ongoing conflicts in Iraq and Afghanistan, there is clearly an urgent need to
conduct more randomized clinical trials research and effectiveness studies in military and Department of
Veterans Affairs PTSD samples. Finally, we provide references to a number of PTSD treatment manuals and
propose several recommendations to help guide clinicians’ treatment selections.
Keywords: PTSD, posttraumatic stress disorder, post-traumatic stress disorder, psychotherapy, psychopharmacology
reveal the ultimate fragility of existence, and can eventuate in both
immediate distress and long-term interruptions to normal functioning with far-reaching consequences for oneself, one’s loved ones,
and society.
The cost of PTSD to the individual is significant in at least four
ways. First, comorbidity is high, with only 17% of veterans with
PTSD diagnosed solely with PTSD (Seal, Bertentha., Miner, Sen,
& Marmar, 2007). Second, PTSD often demonstrates a chronic
course, with as many as 40% of individuals exhibiting significant
symptoms 10 years after onset (Kessler, Sonnega, Bromet,
Hughes, & Nelson, 1995). Third, PTSD is a risk factor for suicide
(e.g., Kotler, Iancu, Efroni, & Amir, 2001). Finally, health problems are more common in individuals with PTSD (e.g., Sledesky,
Speisman, & Dierker, 2008).
The cost of PTSD to society is also significant and exceeds that
of any other anxiety disorder (Marciniak et al., 2005). In the
military, the number of veterans reporting PTSD between 1999
and 2004 grew from 120,265 to 215,871 (a 79.5% increase, Rosenheck & Fontana, 2007). During the same time frame, compensation increased from 1.72 to 4.28 billion dollars (Committee on
Veteran’s Compensation for PTSD, 2007; Institute of Medicine
and National Research Council, 2007).
These various costs and the individual suffering involved underscore the importance of effectively treating PTSD. Although it
has been noted that society has frequently suffered from bouts of
“amnesia” over the importance and prevalence of PTSD (van der
Kolk & McFarlane, 1996), there currently appears to be a steady
interest in PTSD which has yet to abate. This interest has resulted
in the availability of a number of treatment options. However,
clinicians and researchers alike may not be aware of the variegated
approaches which are currently available, or whether there is
evidence in favor of their use. Although combatants and veterans
Posttraumatic stress disorder (PTSD) is an all-too-common consequence of terrifying occurrences, both natural and manmade,
which shock the psychological system and violate core assumptions that life is predictable, safe, and secure. Such events often
Editor’s Note. This article was submitted in response to an open call for
submissions concerning the provision of Psychological Services by practitioner psychologists to veterans, military service members, and their
families. This collection of 12 articles represents psychologists’ perspectives on the mental health treatment needs of these individuals along with
innovative treatment approaches for meeting these needs.—JEB
BRIAN A. SHARPLESS received his PhD in Clinical Psychology and MA in
Philosophy from Pennsylvania State University. He is Clinical Assistant
Professor of Psychology and Assistant Director of the Psychological Clinic
at the same institution. His research interests include anxiety, psychotherapy research, isolated sleep paralysis, therapist competence, psychoanalytic
psychotherapy, and the philosophical foundations of clinical psychology.
JACQUES P. BARBER received his PhD in Clinical Psychology from the
University of Pennsylvania. He is Professor of Psychology in Psychiatry at
the University of Pennsylvania Center for Psychotherapy Research and an
investigator at the MIRECC and at the CESATE of the Philadelphia VA
medical center. His funded research and interests include the study of the
efficacy of different forms of psychotherapy for patients with various
disorders including depression, panic, and PTSD. In addition, he is interested in the mechanisms of change involved in those interventions focusing
his research on both examining the impact of the therapeutic relationship
and of the specific techniques used in therapy on patients’ outcome.
THIS RESEARCH was supported in part by NIMH R01 MH 070664 (held by
Jacques Barber). The views expressed in the paper represent the views of
the authors and are not those of the Department of Veterans Affairs.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Brian
A. Sharpless, Department of Psychology, Pennsylvania State University,
314 Moore Building, University Park, PA 16802. E-mail: bas171@psu.edu
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SPECIAL ISSUE: PTSD TREATMENTS
will likely first seek out help from the Department of Defense
(DoD) and the Department of Veterans Affairs (VA), some of
these individuals may present to private practitioners for treatment.
This may prove challenging. For example, unless one has had
experience in a VA setting, civilian clinicians may not be as
familiar with the nature and intensity of combat traumas as they
are with other types of trauma. These may “feel” somewhat different to treat (even though, functionally, they all may eventuate in
PTSD), as returning soldiers not only suffer from more “standard”
traumatic events (e.g., witnessing a friend die, being raped), but
may also experience PTSD symptoms due to actions they have
themselves taken (e.g., killing enemy combatants). Similarly, practitioners may not be aware of treatment as it is typically provided
in VA settings.
Therefore, this paper will first briefly describe the features of
many PTSD treatments and their place in current practice guidelines. Second, we summarize the relevant outcome literatures and
evaluate the evidence in favor of their effectiveness. When available, we will provide references to more comprehensive empirical
reviews of individual therapeutic modalities. Third, we discuss
several recommendations for treatment selection and provide the
interested reader with a list of published PTSD treatment manuals
in the Appendix.
Methods To Prevent PTSD
The best way to lessen the damage caused by PTSD would be to
prevent its eventual development following the occurrence of
specific traumatic events (i.e., secondary prevention). Both pharmacological and psychological approaches have been evaluated.
Pharmacological Prevention
Several pharmacological approaches to the prevention of PTSD
have been assessed (e.g., ketamine, cortisol). Likely the most
promising of these is propranolol (Inderal), a beta-adrenergic antagonist (beta-blocker) often used to treat headaches, performance
anxiety, and hypertension. Four efficacy studies (reviewed in
Stein, Kerridge, Dimsdale, & Hoyt, 2007 and McGhee et al., 2010)
have shown mixed results, with only two demonstrating reductions
in PTSD symptoms.
Psychological Approaches
Psychological debriefing was developed to prevent long-term
negative sequelae in the wake of traumatic events. Common interventions include the elicitation of emotional reactions, normalizing reactions, and preparing for PTSD responses (e.g., Dyregov,
1989). Although it has been widely used, reviews of existing
randomized clinical trials (RCTs) found little evidence to support
the belief that psychological debriefing prevents PTSD (e.g., Bisson, McFarlane, Rose, Ruzek, & Watson, 2008). In fact, evidence
exists that it can be detrimental to asymptomatic individuals, and
there appears to be a growing hesitation in the field to employ
emotional processing interventions during early posttraumatic
stages (VA/DoD, 2010). However, the use of other debriefing
techniques (such as support and psychoeducation) has been advocated (e.g., VA/DoD, 2010).
9
Some inroads have been made towards understanding which
clients may benefit from the preventative use of brief (i.e., 4 –5
session) CBT. As described below, CBT techniques such as relaxation and exposure to memories and reminders of trauma have
received a great deal of empirical scrutiny. With acute trauma,
however, current research (reviewed in VA/DoD, 2010) indicates
that only symptomatic clients will likely benefit from these early
interventions. In fact, consonant with the literature on psychological debriefing, early intervention on nonsymptomatic trauma survivors may not only be ineffective, but could be harmful (VA/
DoD, 2010).
In summary, apart from CBT for symptomatic trauma survivors
and the utilization of several techniques of psychological debriefing and “psychological first aid” (e.g., safety, education), no other
preventative recommendations are included in current practice
guidelines.
Methods To Treat PTSD
Psychopharmacology
Psychotropic medications are commonly used for persons with
PTSD. Pharmacotherapy is less time-intensive than psychotherapy, can be administered by nonmental health professionals, and is
much easier to continue in an active combat theater than talk
therapy. However, current guidelines (e.g., National Center for
PTSD, 2009) encourage the use of pharmacotherapy with concurrent psychotherapy.
There have been at least 35 RCTs examining pharmacological
agents for PTSD. Two selective serotonin reuptake inhibitors
(paroxetine [Paxil]; sertraline [Zoloft]) and one serotoninnorepinephrine reuptake inhibitor (venlafaxine [Effexor, Trevilor])
are ranked as first-line treatments in at least four different practice
guidelines (American Psychiatric Association, 2004; VA/DoD,
2010; Davidson et al., 2005; National Center for PTSD, 2009). Of
these, paroxetine and sertraline have Food and Drug Administration approval to treat PTSD, with the former possessing the strongest level of overall empirical support. Per VA/DoD (2010) guidelines, the following are recommended as second-line agents: two
tricyclic antidepressants (amitriptyline [Elavil]; imipramine [Tofranil]), one monoamine oxidase inhibitor (phenelzine [Nardil]),
mirtazapine (Remeron), and nefazodone (Serzone). However, it is
worth noting that the Institute of Medicine (2007) concluded that
there is insufficient evidence for the efficacy of medications for
PTSD, although their use is indeed recommended in many current
treatment guidelines.
Adjunctive pharmacological agents for treating PTSD. In
addition to use of single drugs, there have been several advances
made in augmenting the effects of medication (and psychotherapy)
with other psychotropic drugs. The most widely used are prazosin
(Minipress), D-cyloserine (Seromycin), and atypical antipsychotics. Prazosin, often used to treat hypertension, may be very useful
in reducing nightmares and other sleep disturbances commonly
associated with PTSD (e.g., Raskind et al. 2007). A large scale
(i.e., 13 site) VA study of prazosin is currently underway (personal
communication, Murray Raskind, 5/12/2010), and given its relatively mild side effect profile and utility for nightmares, it appears
to be very promising. D-cyloserine is a broad spectrum antibiotic
which has also been utilized as a cognitive enhancer as well as a
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10
SHARPLESS AND BARBER
facilitator of extinction learning in anxiety disorders (Cukor, Spitalnick, DiFede, Rizzo, & Rothbaum, 2009). However, more data
are needed in PTSD samples using D-cylcoserine. Further, the
atypical antipsychotics (e.g., risperidone [Risperdal]) also hold
promise, and are recommended as adjunctive treatments by VA/
DoD (2010).
International psychopharmacology algorithm project:
PTSD algorithm. In spite of some research gains, little guidance is available to prescribers when medications fail to engender
significant change. Work has begun to address this all-toocommon treatment problem through use of a very detailed treatment algorithm that provides explicit recommendations for sequencing medications in order to maximize response when a
first-line agent does not achieve treatment goals (Davidson et al.,
2005). Although constructed using the best available evidence and
seemingly face valid, it has yet to be empirically supported.
In concluding this section, it is important to note that some
PTSD clients may be hesitant to take medications for a number of
reasons (e.g., some fear that symptoms will merely be masked
[Cochran, Pruitt, Fukuda, Zoellner, & Feeny, 2008]), and may be
more comfortable with talk therapy. No such data on a reticence to
take medications are yet available for military personnel or male
samples. Regardless, psychotherapy remains an important treatment option.
Psychotherapies
Many forms of psychotherapy have been used for PTSD. Approaches derived from the CBT traditions have undergone the
most extensive evaluation thus far, and are currently widely disseminated throughout the VA system. As will be presented in
subsequent sections, other approaches hold promise and warrant
additional consideration and testing.
Prolonged exposure (PE). PE is an approach intended to
reduce PTSD through a modification of the memory structures
underlying emotions such as the ubiquitous fear found in PTSD
(e.g., Foa & Kozak, 1986). It is a manualized treatment typically
consisting of 8-15 weekly 90-minute sessions. The main components of PE include the imaginal revisiting of the clients’ traumatic
memories (i.e., imaginal exposure), recounting them aloud and
discussing the experience immediately after the recounting
(termed “processing”) and in vivo exposure to safe, but traumarelated situations that the client fears and avoids. PE also includes
psychoeducation and training in slowed breathing techniques.
Exposure therapy in general, and PE in particular, has been found
to be highly effective in reducing PTSD symptoms (Powers, Halpern,
Ferenschak, Gillihan, & Foa, 2010; Institute of Medicine, 2007), and
of all the PTSD treatments heretofore described (both pharmacological and psychological) likely possesses the most evidence in favor of
its efficacy. Further, PE was one of only two psychotherapies selected
by the VA and military for widespread dissemination. Evidence in
military and VA samples is beginning to emerge, and there have been
two small studies in VA settings (e.g., Rauch et al. 2009). Preliminary
data also indicate that PE can be readily transported out of academic
settings and into the community (e.g., Schnurr et al., 2007). Thus,
extensive support exists for PE in civilian populations and preliminary
support is available that suggests PE can be effectively utilized in
military settings and with female veterans.
Cognitive processing therapy (CPT).
CPT (Resick &
Schnicke, 1992) shares many of the emblematic components of
CBT (e.g., challenging automatic thoughts) and is typically administered in a 12-session format. Self-blame is a particular treatment focus. CPT also contains an exposure component, but one
quite different from PE. Specifically, clients are instructed to write
about their traumatic events in detail (sensory memories, thoughts,
and feelings), read their accounts to themselves daily, and read
them aloud during sessions. Clinicians assist clients in labeling
feelings and working through “stuck points” in the narratives.
Six studies (four RCTs) have found CPT effective in both
military and civilian samples (Cahill, Rothbaum, Resick, & Follette, 2008). A recent dismantling study (Resick et al., 2008)
demonstrated that, while both are efficacious, the cognitive components of CPT are more effective than written exposure techniques. In summary, CPT has very good data supporting its use in
PTSD, and it was chosen as the other psychological treatment to be
extensively “rolled out” through the VA system.
Eye movement desensitization and reprocessing (EMDR).
EMDR is a structured and manualized treatment that combines
elements of CBT, mindfulness, body-based approaches, and
person-centered therapies. It is clinically guided by the Adaptive
Information Processing Model (Shapiro & Maxfield, 2002) which
proposes that traumatic memories in PTSD are unprocessed and
are not stored as memories, but are treated as if they were new
sensory inputs. There are eight phases of treatment in EMDR, of
which the most unique are termed desensitization and reprocessing
(when clients hold distressing images in mind while tracking
rhythmic finger movements of the clinician), the installation of
positive cognitions (during which fingers are tracked while holding positive cognitions in mind), and journaling.
Metaanalyses (reviewed in Spates, Koch, Cusack, Pagoto, &
Waller, 2008) indicate that EMDR is an efficacious treatment with
outcomes not significantly different from exposure-based therapies
in both civilian and military populations. Interestingly, reviews of
the available dismantling studies (e.g., Davidson & Parker, 2001)
indicate that finger tracking and other forms of kinesthetic stimulation do not incrementally add to outcome. EMDR has been
deemed efficacious by the International Society for Traumatic
Stress (as reviewed in Shapiro & Maxfield, 2002), and is recommended in VA/DoD (2010) treatment guidelines. However, these
same guidelines question the theoretical and empirical grounding
of some of the more novel components of EMDR.
Stress inoculation training (SIT). SIT is a package of techniques (relaxation, thought stopping, in vivo exposure to feared
situations) initially developed to manage anxious symptoms that
has been subsequently adapted to PTSD and other specific disorders (e.g., Foa, Rothbaum, Riggs, & Murdock, 1991). SIT has been
shown to be effective in eight studies (four RCTs) with groups of
male veterans and female sexual assault victims (Cahill et al.,
2008). Thus, SIT appears very promising. However, more RCTs
assessing the full treatment package (including exposure components which are sometimes omitted when SIT is used as a control
condition) are needed.
Exposure therapy using virtual reality (VR).
Exposure
need not take place imaginally or in vivo, as it is possible to expose
PTSD clients to traumatic situations via VR. VR may include
convincing visual stimuli, 3D sound, smells, and a general feeling
of immersion in traumatic situations (Rizzo, Reger, Gahm, Difede,
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SPECIAL ISSUE: PTSD TREATMENTS
& Rothbaum, 2009). The efficacy of VR for anxiety disorders is
well supported, and several non-RCT studies (reviewed in Rothbaum, 2009) involving veterans and world trade center disaster
victims are encouraging. The “Virtual Iraq” scenario is currently
being implemented in at least 19 military sites (Rizzo et al., 2009).
From a clinical standpoint, VR may be useful for individuals who
have difficulties vividly imagining their traumas or those resistant
to talk therapy. In one study of Army personnel, 20% of those
unwilling to seek traditional psychotherapy were amenable to
using a VR-based treatment (Wilson, Onorati, Mishkind, Reger, &
Gahm, 2008). However, the current cost of VR systems (⬃$1,500)
may be prohibitive for some practitioners, especially since it is
unknown if the results of VR exposure would justify the expense.
Thus, RCTs are needed, as are studies comparing the efficacy of
VR exposure to more traditional modes of exposure.
Relaxation training. Relaxation training may be the earliest
behavioral treatment for PTSD, and consists of using various
techniques (e.g., successive tension and relaxation of muscles) in
order to reduce the fear and anxiety associated with traumatic
responses. It has been used as a standalone treatment (often as a
control) and as a component of broader PTSD treatments. Relaxation training has been used in four RCTs, and while certainly
effective, it is not as effective as more comprehensive treatment
packages (Cahill et al., 2008).
Cognitive behavioral group therapies. There have been at
least 14 studies (four RCTs) of group CBT for PTSD (Shea,
McDevitt-Murphy, Ready, & Schnurr, 2008), including one large
study of Vietnam War veterans (Schnurr et al, 2003). In this study,
360 male veterans were randomized to either Trauma Focused Group
Therapy or a nonspecific treatment control. Clients improved significantly, but no differences between groups were found. Subsequent
analyses suggested that numbing and avoidance symptoms were reduced more in the Trauma Focused Group Therapy than in the
nonspecific treatment control. After reviewing the literature, Shea and
colleagues (2008) concluded that there is significant support for group
CBT approaches for PTSD, with similar pre-post mean effect sizes
between veteran and sexual abuse samples.
In summary, of the psychotherapies outlined above (i.e., those
which have undergone the most empirical testing), PE, CPT, and
EMDR possess the most evidence in favor of their efficacy and
utility with veterans. Nevertheless, there is a need for larger
comparative trial studies involving combat veterans. We should
note that we have omitted Acceptance and Commitment Therapy
(ACT) and individual mindfulness techniques from this review, as
there are currently no empirical studies of these approaches with
PTSD samples (see Cukar et al., 2009). There have, however, been
studies for the other treatment modalities below.
Psychodynamic psychotherapy. The psychodynamic therapies encompass myriad treatment approaches which share common assumptions that symptoms are meaningful, there are multiple
levels of mental life (i.e., conscious, unconscious), psychopathology is situated in prior developmental events, and aspects of the
therapeutic relationship (e.g., transference, countertransference,
the alliance) are important agents of change (e.g., Summers &
Barber, 2009; Boswell et al., in press). One RCT conducted for
PTSD (Brom, Kleber, & Defares, 1989) found that trauma desensitization, hypnotherapy, and psychodynamic therapy were more
effective than a waitlist control group. Other, less controlled trials
(e.g., Lindy,1988) as well as both insight- and process-oriented
11
dynamic groups, have demonstrated efficacy (Shea et al., 2008).
Taken together, the available empirical base of psychodynamic
therapy, while often lacking in empirical controls, appears compelling enough to warrant its use. This may especially be the case
with PTSD clients who are unwilling to undergo exposure techniques early in treatment, clients with Axis-II pathology, or in
other complex cases where interpersonal themes predominate.
Interpersonal psychotherapy (IPT).
IPT, a time-limited
therapy initially formalized to treat major depression, has subsequently been adapted to PTSD. The central tenet of IPT for PTSD
is that “Trauma impairs the individual’s ability to use the social
environment to process environmental trauma, shattering perceived environmental safety and poisoning trust in interpersonal
relationships (Markowitz, Milrod, Bleiberg, & Marshall, 2009, p.
136).” Thus, IPT for PTSD is intended to increase social skills,
reduce feelings of helplessness and demoralization, increase
agency, facilitate corrective emotional experiences, and assist in
generating adaptive coping strategies.
Bleiberg and Markowitz (2005) conducted an open trial of IPT
for 14 clients. Of those who completed the protocol, 69% were
“responders,” and 36% remitted. Anger and depressive symptoms
improved as well. These preliminary results await replication with
random assignment and controls. Such a study (comparing IPT to
PE) is currently underway at Columbia University, and its results
may help to provide clients with another option for nonexposurebased treatment.
Dialectical behavior therapy (DBT). DBT is a blend of CBT
and mindfulness training developed for the treatment of borderline
personality disorder. A PTSD-focused version has been recently
developed, as this population often shares difficulties with affect
regulation and interpersonal relationships. DBT psychotherapists
oscillate between acceptance/tolerance of the client and attempting
to change the client’s behaviors. Behaviors which interfere with
therapy (e.g., parasuicidal acts) are prime treatment targets, and
individual therapy sessions are supplemented with DBT skill
groups. In addition, a peer supervision/support group for clinicians
is built into this treatment model (Linehan, 1993). DBT has been
evaluated as either a standalone treatment or as an adjunctive
treatment (by using the skills groups) with exposure-based therapies in four studies, but none included veterans (Cahill et al.,
2008). In summary, DBT appears to be a promising treatment for
PTSD. Although it has been empirically tested in limited types of
PTSD clients, DBT’s emphasis on suicidal/parasuicidal behaviors
may make it particularly well suited for use with veterans, a
population with an elevated suicide risk (Kotler et al. 2001).
Hypnosis. Hypnosis has been utilized as both an adjunctive
technique and a stand-alone therapy. Metaanalyses indicate that
hypnosis is an effective adjunct for psychodynamic and CBT
therapies (e.g., Cardeña, Maldonado, van der Hart, & Spiegel,
2008). Similarly, a recent RCT of combat veterans (Abramowitz,
Barak, Ben-Avi, & Knobler, 2008) found that adjunctive hypnotherapy reduced PTSD and insomnia symptoms more than adjunctive zolpidem (Ambien). Taken together, these findings indicate
that hypnosis may be useful.
Treatment Recommendations
As is clear from above, there is no paucity of treatments or
treatment guidelines available for use with clients suffering from
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SHARPLESS AND BARBER
PTSD (e.g., VA/DoD, 2010), and we encourage readers to be
familiar with both sets of resources. However, as is often the case
in clinical psychology, there is much less empirical evidence with
which to rationally guide one’s ultimate treatment selection than
clinicians may hope for. Thus, an ability to empirically make
nuanced and prescriptive treatment decisions using preexisting
client variables (e.g., type of trauma, gender) is currently only in
the beginning stages. If one relies solely upon empirical evidence
(which we believe should be a prime, if not the prime, consideration), then PE, CPT, and EMDR are the psychotherapies of choice
(with priority given to PE), and paroxetine, sertraline, and venlafaxine the most promising medications.
However, there are other practical realities to contend with, such
as the facts that individual practitioners are unlikely to have access
to many of the resources available at VAs and that no psychotherapist possesses competence in all modalities. These facts may limit
the ability to follow treatment guidelines. Therefore, these guidelines will realistically be only one of many considerations used
when determining the best means of intervening with PTSD clients. Given this state of affairs, we encourage clinicians to supplement these guidelines with consideration of relevant resources,
therapy goals, and the degree of client suffering.
Relevant client resources to consider include such factors as the
time and money available for treatment, readiness for change,
motivation to deal actively with the trauma, openness to particular
treatment modalities, and psychological mindedness. For example,
a client who is open to exposure would be well-suited to PE or
CPT. If this same client was averse to exposure, other time-limited
alternatives are available (e.g., IPT). In the case of clients who are
resistant to the “opening up” required for talk therapies, and initial
forays into the reasons for their hesitancy are unsuccessful (i.e., the
client remains adamantly opposed to therapy), referral to a competent psychiatrist for medication management would be appropriate.
Psychotherapist resources to consider primarily include the
range of their competent therapeutic intervention. Clinicians do not
receive uniform training, and some may not have direct experience
with manualized, empirically supported approaches. Lacking either competence in a PTSD treatment or ongoing consultation/
supervision, practicing in an unfamiliar modality may be a violation of the American Psychological Association’s (2002) Ethics
Codes. Fortunately, as our review demonstrates, most orientations
have received some degree of empirical support, albeit limited. If
one has a practice where PTSD clients are likely to be seen, and in
the absence of additional training and supervision (see below), we
recommend choosing the supported modality most closely within
the range of one’s competence and then taking steps to learn the
empirically supported adaptation for PTSD. Providing appropriate
referrals for clients that one does not feel confident to treat is
another (and perhaps the best) solution.
Client preferences and goals for treatment also affect treatment
choice and length. Goals may range from pure symptom relief to
broader wishes to improve relationships and understand themselves better. These wishes are clearly relevant, and may imply one
modality over another. However, lacking data, we could imagine
clients for whom a more exploratory treatment (e.g., psychodynamic therapy) would be indicated, but could just as easily envision scenarios in which this would be a poor match for goals, and
that PE would be a better option. Nevertheless, preferences, especially when very strong, are something to carefully consider.
Finally, a thorough assessment and thoughtful consideration of
a client’s degree of suffering is another key element of treatment
choice. Relevant variables include, but are not limited to, comorbid
psychopathology (e.g., personality disorders, other anxiety disorders) and the presence of cognitive limitations (preexisting or due
to traumatic brain injuries). As one example, a client with significant Axis-II pathology who regularly engages in parasuicidal
behaviors may benefit from a longer-term treatment approach such
as DBT or psychodynamic therapy. In contrast, a client with
comorbid agoraphobia may be helped by an exposure-based protocol modified to address both sets of problems. In contrast to this
type of minor modification to treatment, working with traumatic
brain injury clients with serious cognitive deficits may require a
more extensive adaptation of treatment manuals (e.g., using multiple memory aids or involving family members in order to facilitate the completion of homework). Furth