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 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 pre-existing 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.
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 (pre-existing 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.