Psychology Expert Needed

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References

Sharpless, B. A., & Barber, J. P. (2011). A clinician’s guide to PTSD treatments for returning veterans.

Professional Psychology: Research and Practice, 42(1), 8–15. https://doi-org.library.capella.edu

/10.1037/a0022351

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A Clinician's Guide to PTSD Treatments for Returning Veterans

By: Brian A. Sharpless

Pennsylvania State University;

Jacques P. Barber

University of Pennsylvania;

Philadelphia VA Medical Center, Philadelphia, Pennsylvania

Biographical Information for Authors: 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.

Acknowledgement: 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.

Note: Editor's Note. This article was submitted in response to an open call for submissions

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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

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 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 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

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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).

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

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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 serotonin-norepinephrine

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 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-too-common 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

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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 trauma-related 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.

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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, & 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.

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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 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.

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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 nonexposure-based 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 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

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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

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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). Further, it may be appropriate to recommend that clients seek out a

medication consult, as there are a number of options which may augment psychotherapy (e.g.,

referring a client with disabling nightmares to a psychiatrist for prazosin).

All of the decisions above would be ideally governed by data. Unfortunately, it is difficult to imagine a

time period when this level of empirical support would be available (e.g., Barber, 2009) given the

number of treatments, trauma types, and potentially relevant client variables (e.g., comorbidities).

The number of RCTs required for this would be staggering. Therefore, clinical judgment, knowledge

of idiosyncratic client contexts, and intervention competence are all required supplements to

empirical data (e.g., Sharpless & Barber, 2009).

However, we recommend that clinicians follow lines of empirical evidence when appropriate and

possible. As exposure-based therapies currently have the most support, an ideal scenario we

envision would be for all psychotherapists to enlarge their clinical repertoire with at least one of these

approaches. As the pace of dissemination increases, this should become easier to accomplish, and

there may be novel ways to more seamlessly integrate these techniques into other modalities. At the

present time, however, relatively little is known about the long-term impact of such training on the

ongoing practice of clinicians. In the absence of such data, we recommend a fairly long ongoing

supervision (i.e., six months to a year) subsequent to didactic training as well as studies to examine

the effect of such training on clinicians' practices.

Discussion

In conclusion, exposure therapies (notably PE and CPT) and EMDR have been widely adopted in

practice guidelines, and existing research suggests that they are effective treatments for PTSD.

However, given the heterogeneity of PTSD clients, there are few data supporting the use of one

specific treatment modality over others. More importantly, there is no evidence that a particular

intervention is better suited for a specific trauma type (i.e., rape) or that one treatment is more

effective in military populations. There is also not much evidence that one form of therapy is effective

for all types of traumas, and there is a clear need for more studies examining the efficacy of these

treatments for military personnel and veterans. This may be particularly the case for veterans with

substance abuse issues, but this awaits additional research. As studies become more fine-grained

and numerous, it could become increasingly possible to answer these more specific efficacy

questions. It is also important to note that there is a paucity of research devoted to evaluating the

relative merits of psychotherapy versus medication (and their combination) in veteran samples, and

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more work in this area is needed. We recommend an increased use of effectiveness research

(perhaps through the adoption of standardized treatments and uniform assessment batteries in VAs)

in addition to traditional RCTs, and believe that both will help to facilitate these goals.

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APPENDIX

APPENDIX A

We have compiled major published manuals should the reader wish to delve more deeply into the

respective techniques of these approaches. Many were constructed for use in RCTs, but in our

experience therapy manuals can be readily adapted to more naturalistic settings. We should also

note that some of the manuals discussed above (e.g., interpersonal therapy for PTSD) have yet to be

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published, and in lieu of these we have listed their more general manuals. Further, the requirements

of some approaches (e.g., PE's standard session length of 90 minutes to order allow time for

activation of fear structures or DBT's use of skills groups) may require varying degrees of

modification to a practitioner's standard operating procedures. However, these are the exceptions to

the rule, and creativity and an adherence to the underlying principles encapsulated within the

treatment manuals will likely be beneficial for clients (as they are benefitting from tested therapeutic

approaches) and clinicians (as they are learning new approaches for specific disorders and being

active consumers of research) alike.

We should note that the APA (2002) Ethics code, Standard 2.01, which discusses the boundaries of

professional competence, states that it is an ethical obligation to ensure that psychologists have an

appropriate level of training and experience before providing treatments. Further, when expanding

the range of their competence, psychologists should receive relevant education, supervised

experience, consultation, or study. As many of the PTSD treatments are very specific and time-

limited, augmenting previous clinical experience with expert supervision is strongly recommended.

PTSD Treatment Manuals

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD:

Emotional processing of traumatic experiences: Therapist guide. New York: Oxford University Press.

Gaston, L. (1995). Dynamic therapy for post-traumatic stress disorder. In J. P.Barber & P.Crits-

Christoph's (Eds.), Dynamic therapies for psychiatric disorders: Axis I. New York: Basic Books.

Horowitz, M. J. (1997). Stress response syndromes: PTSD, grief, and adjustments disorders. New

York: Aronson.

Horowitz, M. J. (in press). Assessment-based treatment of post traumatic stress disorders. Sausalito,

CA: Greyhawk Publishing.

Leeds, A. M. (2009). A guide to the standard EMDR protocols for clinicians, supervisors, and

consultants. New York: Springer Publishing.

Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New

York: Guilford Press.

Parnell, L. (2007). A therapist's guide to EMDR: Tools and techniques for successful treatment. New

York: W. W. Norton & Company.

Resick, P. A., & Schnicke, M. K. (1996). Cognitive processing therapy for rape victims: a treatment

manual. Newbury Park, CA: Sage Publications.

Resick, P. A., Monson, C. M., & Chard, K. M. (2007). Cognitive processing therapy: Veteran/military

version. Washington, DC: Department of Veterans Affairs. ( http://cpt.musc.edu/index)

Rubin, A., & Springer, D. W. (Eds.). (2009). Treatment of traumatized adults and children: Clinician's

guide to evidence-based practice. Hoboken, NJ: John Wiley & Sons.

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Schauer, M., Neuner, F., & Elbert, T. (2005). Narrative exposure therapy: A short-term intervention for

traumatic stress disorders after war, terror, or torture. Cambridge, MA: Hogrefe & Huber.

Walser, R. D., & Westrup, D. (2007). Acceptance and commitment therapy for the treatment of post-

traumatic stress disorder and trauma-related problems: A practitioner's guide to using mindfulness

and acceptance strategies. Oakland, CA: New Harbinger.

General Therapy Manuals Adaptable to PTSD

Bernstein, D. A., Borkovec, T. D., & Hazlett-Stevens, H. (2000). New directions in progressive

relaxation training: A guidebook for helping professionals. Westport, CT: Praeger.

Dimeff, L. A., Koerner, K., & Linehan, M. M. (2007). Dialectical behavior therapy in clinical practice:

Application across disorders and settings. New York: Guilford.

Nash, M. (2008) Foundations of clinical hypnosis. In M. R.Nash & A. J.Barnier (Eds.), The Oxford

handbook of hypnosis (pp. 487–502).

Summers, R. J., & Barber, J. P. (2010). Dynamic psychotherapy: A guide to evidence-based practice.

New York: Guilford Press.

Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2007). Clinician's quick guide to interpersonal

psychotherapy. New York: Oxford University Press.

Submitted: August 6, 2010 Revised: November 8, 2010 Accepted: November 12, 2010

This publication is protected by US and international copyright laws and its content may not be

copied without the copyright holders express written permission except for the print or download

capabilities of the retrieval software used for access. This content is intended solely for the use of the

individual user.

Source: Professional Psychology: Research and Practice. Vol. 42. (1), Feb, 2011 pp. 8-15)

Accession Number: 2011-04544-002

Digital Object Identifier: 10.1037/a0022351

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