PTSD: National Center for PTSD
Overview of Psychotherapy for PTSD
Overview of Psychotherapy for PTSD
The VA/DoD PTSD Clinical Practice Guideline (CPG) for Posttraumatic Stress Disorder (2017) offers evidence-based recommendations for the treatment of PTSD.(1) The CPG recommends individual trauma-focused psychotherapies, particularly Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and Eye Movement Desensitization and Reprocessing (EMDR) as the most effective treatments for PTSD.
Individual Trauma-Focused Psychotherapy Recommended Over Other Treatments for PTSD
The CPG (2017) recommends treating PTSD using individual trauma-focused psychotherapy (e.g., 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, two recent meta-analyses compared the treatment effects of psychotherapies and pharmacotherapies. (2,3) The results showed that trauma-focused psychotherapies lead to greater improvement in PTSD symptoms than medications, and that these improvements last longer. In addition, the risks for negative side effects or negative reactions are generally greater with medication than with psychotherapy.
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 treatment using medication (specifically, sertraline, paroxetine, fluoxetine, or venlafaxine; see Clinician's Guide to Medications for PTSD) or certain individual, manualized psychotherapies that are not trauma-focused (specifically, Stress Inoculation Training [SIT], present centered therapy [PCT], and Interpersonal Psychotherapy [IPT]; see below). 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 recent meta-analyses suggest that either one can reduce PTSD symptoms. (2,3)
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 (5), CPT(6), and EMDR (7,8). 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. Other manualized protocols that have sufficient evidence to recommend use are: specific cognitive behavioral therapies for PTSD (9-17), Brief Eclectic Therapy (BEP; 18-20), Narrative Exposure Therapy (NET; 21,22),and written narrative exposure (23,24). There are other psychotherapies that meet the definition of trauma-focused treatment for which there is currently insufficient evidence to recommend for or against their use. (1)
Trauma-Focused Psychotherapies with the Strongest Evidence
The greatest number of studies has 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. (26) 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. (27) 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. (28) 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. (5)
CPT (29), one of the most well-researched cognitive approaches, has a primary focus on challenging and modifying maladaptive beliefs related to the trauma, but also includes 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. (30) 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. (23) Results indicated significant improvement in PTSD and depression for participants in all three 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. (23)
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. (31,32) 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. (33)
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. (6) Two well-controlled studies compared EMDR to PE. One study found equivalent results (8) while the other found PE to be superior (34). 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 Trauma-Focused Psychotherapies with Sufficient Evidence to Recommend for the Treatment of PTSD
There are several specific manualized cognitive behavioral therapy protocols with at least one trial suggesting they help reduce symptoms of PTSD. (9-17) For example, Ehlers and Clark (35) have developed a cognitive therapy for PTSD that involves three 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 have compared cognitive therapy to a waitlist, both with positive results. (15,36)
BEP has a strong psychodynamic perspective (18-20,37) but also incorporates imaginal exposure, written narrative processes, cognitive restructuring through attention to meaning and integration of the experience, relaxation techniques, and a metaphorical ritual closing to leave the traumatic event in the past and foster a sense of control.
NET relies on imaginal exposure through a structured oral life-narrative process that helps patients integrate and find meaning in multiple traumatic experiences across their lifespan. NET has been shown to be an effective and simple way to deliver exposure therapy. (21,22)
Written narrative exposure therapies focus on writing about the trauma memory. The CPT dismantling study evaluated written narrative exposure. (23) Specifically, the CPT written account of the treatment condition included patients writing detailed accounts of their worst trauma in session, reviewing the accounts with the therapist, and then rereading it for homework. (23) Written narrative exposure has also been evaluated in a different paradigm called Written Exposure Therapy (WET). (24,25) Over five 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. Written narrative exposure therapies have been shown to be effective as standalone treatment for PTSD. (23-25)
Psychotherapies to Consider When Individual Trauma-Focused Therapies Are Not Available or Not Chosen by the Patient
Although evidence supports the use of trauma-focused psychotherapies for the treatment of PTSD, access to these treatments is not uniform across clinics. In addition, not all patients are willing to participate in treatments that may focus on their trauma to any extent. As a result, some practitioners utilize non-trauma-focused therapies. SIT, PCT and IPT are the non-trauma-focused therapies with the most evidence derived from clinical trials that have involved direct comparisons with strongly recommended trauma-focused therapies. These treatments differ in their focus and techniques, but are similar in that none of them include a direct exposure to, or cognitive focus on, the traumatic event(s).
- SIT is a form of cognitive restructuring targeting individual thinking patterns that lead to stress responses in everyday life. (28,38)
- PCT focuses on current problems in a patient's life that are related to PTSD. (28,39)
- IPT focuses on the impact that trauma has had on an individual's interpersonal relationships. (40,41)
Evidence for the recommendation supporting non-trauma-focused SIT, PCT and IPT is based largely on two comprehensive meta-analyses, as well as other studies. (37,42) Overall, treatment effects for non-trauma-focused therapies are not as large as those seen in trauma-focused therapies, and the limited number of studies leads to low confidence in the evidence and weak support for the recommendation. However, the evidence shows that these treatments are better than receiving no treatment. A potential advantage of non-trauma-focused treatments is that dropout rates are often lower than those of strongly recommended trauma-focused therapies.
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. For example, despite the appeal of group treatments, results of the few randomized controlled trials of group therapy have been mixed. (43-47) Results of studies indicate that group therapy is not as effective as individual therapy for PTSD. However, group psychotherapy is better than no treatment in reducing PTSD symptoms. (48)
A wide variety of manualized protocols, including Dialectical Behavior Therapy (49), Skills Training In Affect and Interpersonal Regulation (50), Acceptance and Commitment Therapy (51), Seeking Safety (52), hypnosis (53), brief psychodynamic therapy (54), and supportive counseling (12,14,55) have all been used in the treatment of PTSD. However, at this time there are insufficient data conclude whether these treatments are helpful (or harmful) to individuals with PTSD. More research is needed in order to make a recommendation for or against their routine use in patients with PTSD.
In some cases, Veterans 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. (56,57)
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. (19,58-62) Several studies have examined the potential benefits of adding cognitive restructuring to exposure, with two studies finding benefit (14,63) and two studies finding no benefit (5,16). A systematic review of these studies found no added benefit of cognitive restructuring for PTSD symptom severity, loss of PTSD diagnosis, and depression symptoms. (40) 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. (23) The cognitive only group (known as CPT-C) 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. (64)
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, individual trauma-focused psychotherapies such as 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. Specific medications 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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