PTSD: National Center for PTSD
Overview of Psychotherapy for PTSD
Overview of Psychotherapy for PTSD
The revised Departments of Veterans Affairs and Defense (VA/DoD) Clinical Practice Guideline (CPG) for Posttraumatic Stress Disorder (2023), as well as other clinical practice guidelines for the treatment of PTSD, recommends 3 specific trauma-focused psychotherapies, Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and Eye Movement Desensitization and Reprocessing (EMDR), as the most effective treatments for PTSD.
In This Article
Individual Trauma-Focused Psychotherapy Recommended Over Other Treatments for PTSD
The VA/DoD CPG (2023) recommends treating PTSD using individual trauma-focused psychotherapy (specifically PE, CPT, EMDR) over medications based on the current state of the PTSD treatment research (1). Although there have been few direct head-to-head comparisons of trauma-focused psychotherapy and a first-line medication for treating PTSD, a recent meta-analysis by Merz and colleagues (2019) examined comparative effectiveness studies and concluded there was greater benefit of psychological treatments (2). Two prior meta-analyses that compared the treatment effects of psychotherapies and pharmacotherapies (3,4) also showed that trauma-focused psychotherapies lead to greater improvement in PTSD symptoms than medications, and that these improvements last longer. Restricting the studies to the subset that included active controls did not change the results. In addition, the risks for negative side effects or negative reactions are generally greater with medication than with psychotherapy. A notable exception was a recent randomized controlled trial (RCT) that compared PE to sertraline and the combination (PE + sertraline) and found no differences. However, in that study medication management was more extensive than typical medication management (5).
Individual trauma-focused psychotherapies may not be available in all settings and not all patients choose to engage in these treatments. In such cases, the CPG recommends certain individual, manualized psychotherapies (specifically, Cognitive Therapy (6), Written Exposure Therapy [WET], and Present Centered Therapy [PCT]; see below) or using medication (specifically, sertraline, paroxetine or venlafaxine; see Clinician's Guide to Medications for PTSD). There are no data to guide whether medication or non-trauma-focused psychotherapy is more effective in cases where trauma-focused psychotherapy is unavailable or not desired. Results of meta-analyses suggest that either one can reduce PTSD symptoms (2-4).
The CPG defines trauma-focused psychotherapy as therapy that uses cognitive, emotional, or behavioral techniques to facilitate processing a traumatic event and in which the trauma focus is a central component of the therapeutic process (4). The trauma-focused psychotherapies with the strongest evidence from clinical trials are PE, CPT, and EMDR (7-15). These treatments have been tested in numerous clinical trials, in patients with complex presentations and comorbidities, in comparison to active control conditions, and with long-term follow-up designs. Furthermore, these treatments have been validated by research teams other than the developers. There are other psychotherapies that meet the definition of trauma-focused treatment for which there is currently weak or insufficient evidence to recommend for or against their use (1).
Trauma-focused psychotherapies with the strongest evidence
The greatest number of studies have been conducted on exposure-based treatments, which involve having survivors repeatedly think about or re-tell their traumatic event. PE has received the most attention. PE includes both imaginal exposure and in vivo exposure to safe situations that have been avoided because they elicit traumatic reminders (16). In a multisite randomized controlled trial of PE in female Veterans and active-duty personnel with PTSD, those who received PE experienced greater reduction of PTSD symptoms relative to women who received Present-Centered Therapy and were less likely to meet PTSD diagnostic criteria (17). Moreover, PE was more effective than the combination of PE plus Stress Inoculation Training (SIT), SIT alone, or a waitlist control in female sexual assault survivors (18). In addition, PE alone and PE plus cognitive restructuring reduced PTSD and depression relative to a waitlist control in intention-to-treat and completer samples (19).
Continuing Education Course
Practical Applications of Trauma-Focused Psychotherapies
This course describes CPT, EMDR and PE, using a case vignette to illustrate the clinical delivery of each of these trauma-focused psychotherapies.
CPT (20), one of the most well-researched cognitive approaches, has a primary focus on challenging and modifying maladaptive beliefs related to the trauma, but can also include a written exposure component. Veterans with chronic military-related PTSD who received CPT showed better improvements in PTSD and comorbid symptoms than the waitlist control group (21). A dismantling study of CPT then examined the relative utility of the full protocol compared with its components: cognitive therapy alone and written exposure alone (22). Results indicated significant improvement in PTSD and depression for participants in all 3 treatments. However, the cognitive therapy alone resulted in faster improvement than the written exposure alone, with the effects of the full protocol of CPT falling in-between (22).
Patients receiving EMDR engage in imaginal exposure to a trauma while simultaneously performing saccadic eye movements. There is disagreement regarding the extent to which eye movements add to the effectiveness of EMDR. Two prior meta-analyses found no incremental effect for the eye movement component of EMDR (23,24). A more recent meta-analysis showed support for the effectiveness of eye movements, although the evidence was stronger for the impact of eye movement on self-reported distress than on PTSD symptoms (25).
CPT, PE and EMDR have shown great success in outcome research; thus, one logical research question involves whether one is more effective than the other. In a head-to-head comparison, CPT and PE were equally effective in treating PTSD and depression in female sexual assault survivors (26). Two well-controlled studies compared EMDR to PE. One study found equivalent results (27) while the other found PE to be superior (28). More information is needed to understand who benefits most from which of these evidence-based treatments. At this time, a patient-centered approach using shared decision-making with the patient and provider is recommended as the optimal way to choose among available treatments (1).
Other Psychotherapies With Sufficient Evidence to Recommend for the Treatment of PTSD
There are several other trauma-specific manualized cognitive behavioral therapy protocols that are suggested to reduce symptoms of PTSD (6,29-36). For example, Ehlers and Clark (37) have developed a cognitive therapy for PTSD that involves 3 goals: modifying excessively negative appraisals, correcting autobiographical memory disturbances, and removing problematic behavioral and cognitive strategies. Elements unique to Ehlers and Clark's cognitive therapy include performing actions that are incompatible with the memory or engaging in behavioral experiments. Two randomized controlled trials that used clinician-rated PTSD outcomes compared cognitive therapy to a waitlist and to active control, both with positive results (34,38).
Written Exposure Therapy (WET) focuses on writing about the trauma memory (10,39). Over 5 sessions, patients come to the office and write about their trauma, with attention to details of the event and emotions experienced at the time. The writing is very briefly processed with the therapist during the subsequent session and there is no homework. WET has been shown to be superior to waitlist and non-inferior to CPT (10,39)
Present-Centered Therapy (PCT) is a suggested non-trauma focused alternative. PCT focuses on increasing adaptive responses to current life stressors and difficulties that are directly or indirectly related to trauma or PTSD symptoms. A systematic review of PCT that included 12 studies, found PCT was superior to waitlist and not non-inferior to trauma-focused psychotherapy; however, the effect for trauma-focused psychotherapy was superior to PCT. A potential advantage of PCT is the lower dropout rates as compared to other recommended trauma-focused therapies (40).
Therapies With Insufficient Evidence to Recommend for the Treatment of PTSD
Other treatments may be effective; however, at this time there is not enough evidence to draw conclusions (1). These include Accelerated Resolution Therapy (ART), Adaptive Disclosure (AD), Acceptance and Commitment Therapy (ACT), Brief Eclectic Psychotherapy (BEP), Dialectical Behavior Therapy (DBT), Emotional Freedom Techniques (EFT), Impact on Killing (IoK), Interpersonal Psychotherapy (IPT), Narrative Exposure Therapy (NET), Prolonged Exposure in Primary Care (PE-PC), psychodynamic therapy, psychoeducation, Reconsolidation of Traumatic Memories (RTM), Seeking Safety (SS), Stress Inoculation Training (SIT), Skills Training in Affective and Interpersonal Regulation (STAIR), Skills Training in Affective and Interpersonal Regulation in Primary Care (STAIR-PC), supportive counseling, Thought Field Therapy (TFT), Trauma-Informed Guilt Reduction (TRiGR), or Trauma Management Therapy.
In some cases, an individual may prefer PTSD treatment that includes attention focused on their intimate relationships. It is not yet known if a couples-based approach is as effective as individual trauma-focused therapy for PTSD. Overall, there is promising but limited evidence in support of trauma-focused couples therapy for PTSD (41,42).
Individuals may also be interested in group treatments. However, here too there is insufficient data to make a recommendation. A recent systematic review by Schwartze and colleagues (2019) found mixed results of trauma-focused groups to no treatment and no difference between non-trauma-focused treatments and no treatment controls. No group treatments were found to be superior to active controls nor was there benefit to adding group as an adjunctive treatment (43). One study found individual CPT was more effective than group CPT (44).
Some patients with PTSD will have an inadequate treatment response even after successful delivery of one or more courses of trauma-focused psychotherapy or other evidence-based treatments. There is no consensus in the literature on how to optimally approach the care of these patients. Patient preferences and clinical judgment are important in determining the best course of action in such cases.
Adding or Removing Components of Evidence-Based Treatments Is Not Recommended
Some investigators have added a novel component to an effective treatment in hopes of further optimizing outcomes (45-50). Several studies have examined the potential benefits of adding cognitive restructuring to exposure, with 2 studies finding benefit (33,51) and 2 studies finding no benefit (19,35). A systematic review of these studies found no added benefit of cognitive restructuring for PTSD symptom severity, loss of PTSD diagnosis and depression symptoms (52). A dismantling study of CPT, which includes both a written trauma narrative as well as cognitive therapy, examined full CPT versus the separate narrative and cognitive components (22). The cognitive only group (known as CPT-C in the study) showed faster improvement during treatment on self-rated PTSD outcomes, but the treatments did not differ significantly at post-treatment on clinician-rated PTSD and other outcomes. Based on these findings, the CPT protocol has been modified so that the written narrative is optional, and the standard protocol (now referred to as CPT) includes the cognitive component only (53).
Based on this research, the CPG does not recommend adding or removing components from evidence-based psychotherapy protocols. If modifications to an established protocol (e.g., PE, CPT, EMDR) are clinically necessary, the modifications should be empirically and theoretically guided, and with understanding of the core components of trauma-focused psychotherapies considered most therapeutically active (1).
Overall, PE, CPT and EMDR are the most highly recommended treatments for PTSD and have strong evidence bases. Components of these treatments have been combined with other interventions, with no support for improved benefits over the standard treatments alone. Other trauma-focused and non-trauma-focused psychotherapies can also help reduce symptoms of PTSD. More research is needed before drawing conclusions about the effectiveness of group and other psychotherapies.
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