Reference Work Entry

Handbook of Clinical Psychology Competencies

pp 785-810

Post-Traumatic Stress Disorder

  • Daniel F. GrosAffiliated withRalph H. Johnson VAMC
  • , Peter W. TuerkAffiliated withRalph H. Johnson VAMC
  • , Matthew YoderAffiliated withRalph H. Johnson VAMC
  • , Ron AciernoAffiliated withRalph H. Johnson VAMC


From its initial definition and frequent revisions in the Diagnostic and Statistical Manual of Mental Disorders, assessing and treating posttraumatic stress disorder (PTSD) has presented many challenges to clinicians and researchers alike. However, through advances in cognitive and behavioral theory and practice, a number of evidence-based assessments (EBAs) and evidence-supported treatments (ESTs) have been developed to address this complex disorder. In this chapter, we briefly review the diagnostic features and EBA practices for PTSD. We also detail the mechanisms involved in the maintenance and treatment of PTSD and the EST approaches for the disorder. Finally, we outline the basic and expert clinician competencies involved in the treatment of PTSD from an evidence-based, cognitive-behavioral perspective.


From its initial definition and frequent revisions in the Diagnostic and Statistical Manual of Mental Disorders, assessing and treating posttraumatic stress disorder (PTSD) has presented many challenges to clinicians and researchers alike. However, through advances in cognitive and behavioral theory and practice, a number of evidence-based assessments (EBAs) and evidence-supported treatments (ESTs) have been developed to address this complex disorder. In this chapter, we briefly review the diagnostic features and EBA practices for PTSD. We also detail the mechanisms involved in the maintenance and treatment of PTSD and the EST approaches for the disorder. Finally, we outline the basic and expert clinician competencies involved in the treatment of PTSD from an evidence-based, cognitive-behavioral perspective.

28.1 6.1 Overview

In this chapter, we briefly review the diagnostic features and assessment practices for posttraumatic stress disorder (PTSD). We also detail the mechanisms involved in the maintenance and treatment of PTSD and the evidence-supported treatment (EST) approaches for the disorder. Finally, we outline the basic and expert clinician competencies involved in the treatment of PTSD from an evidence-based, cognitive-behavioral perspective.

28.1.1 6.1.1 Diagnostic Features

As defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2000), PTSD is characterized by (A) exposure to a traumatic event in which the individual experienced, witnessed, or was confronted with an event that involved the actual or threatened death or serious injury to one’s self or others and the individual’s response to said event which involves intense fear and helplessness. Traumatic events that commonly result in PTSD include, but are not limited to, military combat, being a victim of a violent assault or other crimes, natural or man-made disasters, motor vehicle accidents, or being diagnosed with a life-threatening illness. In addition, three symptom clusters are associated with the event, involving: (B) persistent reexperiencing of the traumatic event, including distressing recollections or dreams, acting or feelings as if the event were recurring, and intense psychological distress or physiological reactivity on exposure to cues that symbolize the event; (C) persistent avoidance of stimuli associated with the traumatic event, including avoidance of thoughts, feelings, memories, activities, places, or people that serve as reminders of the trauma, and general emotional numbing, including diminished interested in activities, feelings of detachment, restricted affect, and sense of a foreshortened future; and (D) persistent symptoms of increased arousal, including sleeping disturbance, increased irritability and anger, difficulty concentrating, hypervigilance, and an exaggerated startle response. The symptoms must (E) present for at least 1 month and (F) result in significant impairment in social and/or occupational functioning.

28.1.2 6.1.2 Prevalence, Course, and Risk Factors

Although more than half of all US adults are exposed to at least one traumatic event (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995), lifetime prevalence for PTSD is estimated around 8% of the adult population (American Psychiatric Association, 2000). However, research demonstrates a dose–response relation between the severity of a traumatic event and the onset of PTSD (for review, see Friedman, Resick, & Keane, 2007), whereas prevalence of PTSD is higher among victims of more severe traumatic events (e.g., survivors of rape, childhood sexual abuse, and military combat and captivity). The course of PTSD is variable as the disorder can occur at any age, the symptoms can develop at variable time intervals after the initial traumatic event, and the symptoms can resolve within the first 3 months or persistent for longer than 12 months after the traumatic event (American Psychiatric Association, 2000). Several factors increase risk of PTSD, including pretraumatic (e.g., age, sex, previous trauma history, personal and family psychiatry history, and education level), peritraumatic (e.g., nature of the trauma, dissociation, and panic attacks), and posttraumatic factors (e.g., social support; Friedman et al., 2007).

28.2 6.2 Recognition of Symptoms and Their Assessment

Since the diagnosis was included in the DSM-III (American Psychiatric Association, 1980), psychological assessment and treatment practices for PTSD have received significant attention and frequent revision (Keane & Barlow, 2002). Due to a wide range of symptom presentations, inconsistent relations to trauma exposure (e.g., exposure does not always lead to the development of PTSD), and high rates of comorbidity with other anxiety and mood disorders, the assessment of PTSD can present a challenge to mental health professionals (Keane, Brief, Pratt, & Miller, 2007; Litz, Miller, Ruef, & McTeague, 2002). Nonetheless, a recognition among experts that exposure to potentially traumatic events actually is a normative experience (e.g., natural disasters, interpersonal violence, military conflicts) and a recognition of negative health and economic consequences associated with PTSD highlight the need for adequate assessment and treatment for the disorder (Keane et al., 2007). Fortunately, a number of evidence-based assessments (EBAs) exists that can aid clinicians to identify and investigate the symptoms of PTSD (Keane & Barlow, 2002). The focus of this section of the chapter is on present goals and practices for psychological assessment of PTSD.

28.2.1 6.2.1 Goals for the Assessment of PTSD

Litz et al. (2002) outlined several goals relevant to assessing PTSD symptoms. Although assigning a diagnosis of PTSD is often the primary goal of assessment, there are several other factors to consider, which depend on the context of assessment, needs of the patient, and clinical resources. The primary goals of any assessment of PTSD are to (1) establish the presence and extent of a potentially traumatic event, and (2) complete a diagnostic assessment of PTSD symptoms. However, there may be several secondary goals to PTSD assessment, including: (3) placing a traumatic event or events in a life-span context in order to more fully understand factors that may have contributed to development and maintenance of the disorder, (4) evaluating compensation and litigation status for patients involved in the legal system, and (5) evaluating motivation and readiness for change for patients seeking treatment. Clinicians and researchers should select appropriate measures and tailor assessments to attain each of the desired goals. Descriptions of the various types of assessment instruments for PTSD symptomatology are given below.

28.2.2 6.2.2 Semi-Structured Diagnostic Interviews

Semi-structured clinical interviews utilize a combination of standard clinical interview procedures with focused prompts to assure consistent and valid coverage of relevant parameters for a given disorder. These interviews allow for thorough investigation of clinical presentation and routinely include components of formal batteries to assess specific diagnostic questions (Litz et al., 2002). Although less common in purely clinical settings due to time constraints and specialized training required to administer these interviews correctly, semi-structured clinical interviews can improve diagnostic accuracy and treatment planning and may be useful in hospital and social service settings (Keane & Barlow, 2002; Keane et al., 2007). There are two primary types of semi-structured interviews used to identify PTSD: semi-structured interviews that assess a wide range of symptoms of psychopathology and semi-structured interviews that solely focus on the symptoms of PTSD.

The Structured Clinical Interview for DSM-IV (SCID-IV; First, Spitzer, Gibbon, & Williams, 1996) and Anxiety Disorder Interview Schedule (ADIS; Di Nardo, Brown, & Barlow, 1994) are the two most common general semi-structured interviews used to assess PTSD and related disorders (Keane et al., 2007; Litz et al., 2002). In contrast to the semi-structured interviews that focus solely on PTSD, both the SCID and ADIS assess PTSD and several other anxiety, mood, and related disorders based upon the criteria listed in the DSM-IV. Both interviews have demonstrated excellent validity and reliability findings in the literature (for review, see Keane et al., 2007). One additional benefit of the ADIS is the inclusion of continuous ratings of frequency and intensity of distress for each disorder.

The Clinician-Administered PTSD Scale (CAPS; Blake et al., 1995) is the most commonly used PTSD-focused semi-structured interview (Keane et al., 2007); however, other interviews are available (PTSD Symptom Scale Interview [Foa, Riggs, Dancu, & Rothbaum, 1993]; Structured Interview for PTSD [Davidson, Smith, & Kudler, 1989]). In contrast to the SCID and ADIS, the CAPS provides a wider assessment of PTSD symptoms, including the 17 DSM-defined PTSD symptoms, symptoms of guilt and dissociation related to the traumatic experience, and the impact of one’s symptoms on occupational and social functioning (Litz et al., 2002). In addition, the CAPS includes frequency and intensity ratings for each symptom, which provides continuous descriptors of symptomatology. Similar to the SCID and ADIS, the validity and reliability of the CAPS is well supported (Keane et al., 2007).

28.2.3 6.2.3 Self-Report Questionnaires

Several self-report questionnaires offer time- and cost-efficient ways to assess symptoms of PTSD (Orsillo, 2001). Self-report questionnaires have received widespread acceptance in the PTSD literature due to the ease with which they can be administered and scored (Keane & Barlow, 2002). The primary goals of these measures are to screen for PTSD symptoms, provide dimensional (e.g., intensity) data on symptom level, as well as to related impairment of PTSD, and track treatment progress (Litz et al., 2002). In order for a self-report measure to be considered an EBA, psychometric properties must be well researched, including evidence of test-retest reliability, internal consistency, and content, construct, and criterion-related validity (Antony & Rowa, 2005; Keane et al., 2007).

Self-reported questionnaires vary in a number of important ways. One way in which measures differ is in their targeted symptoms. Some questionnaires, such as the PTSD Checklist (PCL; Weathers et al., 1993), the Purdue PTSD Scale-Revised (PPTSD-R; Lauterbach & Vrana, 1996), and the PTSD Symptom Scale (PSS-SR; Foa et al., 1993), map items directly onto DSM criteria to permit diagnostic classification using DSM algorithms and provide a continuous measure of severity (Litz et al., 2002). These measures tend to be brief with around 20 items each. Alternatively, several other measures, such as the Minnesota Multiphasic Personality Inventory PTSD Scale (MMPI-PTSD; Keane, Malloy, & Fairbanks, 1984) and Mississippi Scale for PTSD (MPTSD; Keane, Caddell, & Taylor, 1988), do not directly assess criterion-related symptoms of PTSD; rather, they assess overall symptom severity and associated impairment. Non-DSM-referenced scales tend to be more time-consuming and contain around 40 items each. Questionnaires also differ in time frame of assessment, whereas some measures assess symptoms over the past month (e.g., PCL and PPTSD-R) and others specify only the past week (e.g., Impact of Event Scale-Revised [IES]; Horowitz, Wilner, & Alvarez, 1979) or specify no time frame at all (e.g., MMPI-PTSD and MPTSD). Together, in combination with the psychometric properties (for review, see Orsillo, Batten, & Hammond, 2001), these characteristics may inform clinician’s decisions regarding choosing an appropriate self-report measure of PTSD symptoms.

28.2.4 6.2.4 Psychophysiology

Psychophysiological methods of assessing PTSD have received significant attention in the literature (Keane & Barlow, 2002; Keane et al., 2007; Litz et al., 2002; Orsillo et al., 2001; Pole, 2007). Psychophysiological methods, including indices of autonomic reactivity (e.g., heart rate, blood pressure, electrodermal response) and emotional reactivity (e.g., facial electromyography), have been used to diagnose PTSD and assess treatment outcome (Keane et al., 2007). Psychophysiological assessment is well suited for PTSD because the DSM diagnostic criteria for the disorder include physiological reactivity to internal or external cues that resemble the traumatic event. However, this DSM criterion is not required for a diagnosis of PTSD and an estimated 40% of individuals with PTSD do not exhibit reactivity, which may reduce the ability of psychophysiological assessments to detect differences in some persons with PTSD (Prins, Kaloupek, & Keane, 1995). In fact, the largest and arguably most rigorous study of the psychophysiology of PTSD involving comparison of four psychophysiological indices and SCID-based PTSD diagnosis in a sample of over 1,300 veterans was successful in classifying only two thirds of those with a current diagnosis of PTSD (Keane et al., 1998). Numerous factors may contribute to the disparity between psychophysiological and self-report indices, including general biological influences (e.g., age, sex, race, and fitness level), methodological factors and protocol demands, and the use of pharmacological agents (Keane et al., 2007; Litz et al., 2002). There also has been some research to suggest that psychophysiological methods may be useful in assessing changes during the course of treatment (Fairbank & Keane, 1982; Shalev, Orr, & Pitman, 1992). Although mostly limited to case studies, there is more optimism for these psychophysiological methods due to their ability to control for individual variability through within-subject designs (Litz et al., 2002). In summary, psychophysiological assessment of PTSD has some value as both a diagnostic tool and an assessment of treatment process, if used with support from alternative forms of assessment, such as self-report measures and structured interviews. However, due to the expense in terms of time and cost, patient burden, the expertise required to administer and interpret the findings, and the efficiency of more economical methods of assessment discussed earlier, the widespread adoption of psychophysiological indices of assessment is limited (Keane & Barlow, 2002).

28.2.5 6.2.5 Limitations and Future Directions

Together, these three approaches to assessment provide a comprehensive evaluation of the symptoms of PTSD; however, several issues should be taken into consideration when discussing current assessment practices. One of the primary concerns is the level of comorbidity and overlap between PTSD and other related disorders, especially depression and the other anxiety disorders (Antony & Rowa, 2005; Brown & Barlow, 2002). Although several of the semi-structured interviews provide information to address these concerns, a majority of self-report measures and psychophysiological indices does not assess comorbidity. A second concern relates to controversies surrounding the symptom clusters of PTSD and the symptoms of anxiety and depression more generally (e.g., Simms, Watson, & Doebbeling, 2002; Watson, 2005). Clinicians and researchers are exploring alternate assessment and classification systems, including expanding the role of functional impairment in assessment (Cohen & Mannarino, 2004), as well as, exploring a broader symptom-based, rather than DSM criterion-based system (Antony & Rowa, 2005).

28.3 6.3 Maintenance Factors of the Disorder or Problem

In the immediate aftermath of a traumatic event (0–48 h), the typical response is one of cognitive, emotional, and behavioral disruption. The event is fresh in memory and a majority of survivors evinces some degree of distress and impairment (Litz & Maugen, 2007). However, the posttraumatic stress literature of the past 20 years demonstrates that most people exposed to traumatic events, approximately two thirds, recover effective functioning within 3 months (Blanchard, Hickling, & Forneris, 1997; Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992). Nonetheless, this leaves a significant number of people for whom the initial trauma-induced distress and impairment does not subside and PTSD develops (Kessler et al., 1995).

Most traumatic events are sudden, unpredictable, outside of the range of normal human experience, and emotionally painful. Enduring symptomatology in the individuals who develop PTSD has been parsimoniously explained by several researchers using conditioning/learning theories (Keane & Barlow, 2002; Kilpatrick, Veronen, & Best, 1985). According to learning theory, a traumatic event (e.g., combat exposure) serves as the original stimulus that leads to an unlearned response comprising PTSD symptoms (avoidance, hyper-arousal, intrusive ideation). These responses become associated with salient stimuli (i.e., “triggers”) present in an individual’s internal (e.g., racing heart) and external environments (e.g., loud noises) during the time of exposure, and these stimuli begin to elicit learned anxiety responses in the future. Thus, when an individual who was exposed to a traumatic event is then exposed to one of these trigger stimuli, a negative emotional PTSD response identical or very similar to the original emotional response occurs. In order to reduce or eliminate aversiveness of this learned anxiety response, individuals will escape from, and subsequently avoid, activities, places, or people that remind them of the event, thereby reducing anxiety in the short term (in response to an escape from conditioned or learned fear stimuli) but perpetuating this maladaptive learned response in the long term (by preventing extinction of the learned response).

Alternatively, several theories of PTSD focus on the thoughts, assumptions, interpretations, and beliefs that are impacted by traumatic events (for a review, see Cahill & Foa, 2007). Under these theories, traumatic events are conceptualized as providing new, often frightening information about one’s self and the world, resulting in the formation of cognitive fear structures (Foa & Kozak, 1986; Foa, Steketee, & Rothbaum, 1989). Cahill and Foa (2007) note:

A fear structure becomes maladaptive or pathological when (1) associations among stimulus elements do not accurately represent the world, (2) physiological and escape/avoidance responses are evoked by harmless stimuli, (3) excessive and easily triggered response elements interfere with adaptive behavior, and (4) harmless stimulus and response elements are erroneously associated with threat meaning. (p. 62)

As such, the ways in which survivors think about the self, the world in which they live, and the meaning of events/stimuli occurring in the world are often disrupted. Thus, according to this theory, posttraumatic distress results from post-event cognitions.

Current theories regarding the enduring nature of PTSD center on avoidance. Indeed, as described earlier, avoidance is one of the three characteristic symptom clusters of PTSD. The types of avoidance that contribute to the maintenance of pathological posttraumatic stress symptoms and to PTSD itself can be organized into two groups: cognitive and behavioral factors. These two categories of avoidance are not necessarily mutually exclusive, but can often be systematically related. However, for purposes of clarity, they will be discussed separately in this section.

28.3.1 6.3.1 Behavioral Avoidance

Given the distress and pain associated with traumatic events, it is understandable that survivors attempt to avoid stimuli which remind them of the trauma(s). However, as learning theory describes (e.g., Mowrer, 1960), after a person is exposed to a life-threatening event, a fear-response, involving aversive sympathetic nervous system arousal, may be elicited by not just stimuli present during the event but, also through processes of higher-order conditioning and stimulus generalization, so that additional stimuli and situations that are associated with either the original traumatic event, or other salient stimuli associated with the event elicit the fear-response (Keane, Zimering, & Caddell, 1985). For example, a victim of sexual assault may associate his or her assault with darkness and the perpetrator (i.e., stimuli present during the event); however, their fear-response may be generalized to all situations involving either nighttime, men, sexual activity, and thoughts/words associated with the rape experience. To avoid distress, the victim may avoid each of these generalized persons, places, situations, including men, sexual activity, and stimuli associated with the rape itself. This avoidance behavior naturally results in diminution of negative emotions in the very short term, in effect (negatively), reinforcing more frequent use of avoidance. However, avoidance also has the negative effect of fostering withdrawal and maintaining PTSD (Mowrer, 1960). Thus, teaching individuals to confront and remain in the presence of previously avoided situations (i.e., expose themselves to these situations) that trigger anxiety will eventually reduce symptoms of PTSD. This anxiety reduction, if structured appropriately, will be complimented by increases in natural reinforcement derived by engaging in previously rewarding activities and may reduce depression.

28.3.2 6.3.2 Cognitive Maintenance Factors

Given that traumatic events are distressing by definition, there is a tendency to cope with the distress of reexperiencing symptoms by attempting to avoid thinking about the event itself in much the same way as behavioral avoidance is manifest in avoiding persons, places, or situations that remind one of the traumatic event. A common response to traumatic memories described by those seeking treatment for PTSD is, “I try not to think about it.” However, research demonstrates that suppressing negative trauma-related thoughts leads, paradoxically, to an increase in thought frequency (Davies & Clark, 1998; Reynolds & Wells, 1999). In fact, Shipherd and Beck (1999) found that after survivors of sexual assault with PTSD were asked to deliberately suppress their negative thoughts, they reported a significant rebound effect of negative thoughts when compared to survivors without PTSD, suggesting that active thought suppression contributed to an increase in negative thoughts.

Various prominent theories of PTSD describe the mechanism by which cognitive avoidance maintains the disorder in different ways, but active behavioral avoidance of trauma-related cognitions and reminders is incorporated into nearly all these theories. For example, schema theories (e.g., Epstein, 1985; Janoff-Bulman, 1992; McCann & Pearlman, 1990) imply that avoidance maintains PTSD by preventing resolution of the discrepancy between pre-trauma internal models (e.g., the world as a safe place) and trauma-related information (e.g., the world is a dangerous place all the time) – a process that requires cognitive processing of the new information. Emotional processing theory (Foa & Kozak, 1985) and Ehlers and Clark’s (2000) cognitive theory note that cognitive avoidance prevents change in the underlying memory, or fear structures, resulting in maintenance of PTSD symptoms.

Avoidance further contributes to PTSD by preventing the survivors from being exposed to information that may challenge their posttrauma beliefs. For example, soldiers returning from combat with PTSD may have learned to associate unknown people (i.e., possible enemy combatants) with danger and therefore avoid situations involving the potential of encountering crowds of people they do not know (e.g., malls, parks, restaurants, etc.). Through behavioral avoidance of social situations, they also are prevented from encountering information incongruent with their belief that strangers are dangerous, thereby maintaining PTSD symptoms.

28.3.3 6.3.3 Conclusion

In short, traumatic events result in behavioral avoidance, learned fear responding to stimuli that were previously neutral, cognitive confusion, and emotional pain. Associations of trauma cues with emotional pain foster avoidance of cues. Behavioral avoidance prevents cognitive and emotional processing, adjustment of erroneous beliefs, and corrective modification of conditioned associations between a fear-response and neutral or positive stimuli. Cognitive avoidance also leads to a paradoxical increase in trauma-related intrusions. Together, these behavioral and cognitive mechanisms have been shown to contribute to the development and maintenance of PTSD; accordingly, decreasing or eliminating avoidance disrupts the maintenance of PTSD symptoms.

28.4 6.4 Mechanisms of Change Underlying the Intervention

As noted above, the typical recovery pattern seen in the majority of people following traumatic events involves modifying the emotional associations and maladaptive automatic cognitions through exposure to feared stimuli. Such exposure promotes cognitive and emotional processing of events that originally may have been experienced as confusing, sudden, or nonsensical. These learning and cognitive processes happen, to a greater or lesser degree, in everyday life through conversations with others about the event and repeated contact with trauma-related cues (e.g., taking the bus to work after the original assault happened at a similar bus stop; going to crowded but safe places such as malls). Avoidant behaviors disrupt this normative process and are thought to be responsible for the maintenance of PTSD (Cahill & Foa, 2007; Kindt, Buck, Arntz, & Soeter, 2007). Given these conceptualizations of the disorder, exposure, reconditioning, and cognitive/emotional processing are all active mechanisms of therapeutic change in symptoms of PTSD. The importance of, and the emphasis given to, each of these varies by specific treatment model; however, the treatments found to be most effective include each to some degree.

Exposure treatment or therapy refers to the process of encountering trauma-related associations, cues, thoughts, and memories. Exposure therapy describes a treatment model generally based on learning theory concepts of extinction and habituation. Exposure also can be conceptualized as the opposite of behavioral and cognitive avoidance, which are the behaviors developed by individuals with PTSD to reduce aversiveness associated with trauma cues. Notably, nonavoidance and exposure foster relearning. As described above, traumatic events may result in pathological associations between a fear-response and external and internal stimuli or cues. Survivors are negatively reinforced (aversiveness is reduced) by avoiding these previously neutral cues. Because they avoid these stimuli, no extinction (unlearning) of the conditioned fear-response is possible, and the constellation of symptoms known as PTSD endures (Rescorla, 2001). Unlearning the fear-response (i.e., unpairing the association between a previously neutral stimulus such as a bus stop and the fear-response such as heightened anxiety) is necessary and achieved through repeated exposure to trauma-related cues (decreasing behavioral avoidance). In addition to the basic conditioning principal of extinction, these experiences also provide survivors with information and evidence that may modify learned maladaptive cognitions acquired during the traumatic event. For example, a combat veteran who associates strangers or crowds with a fear-response (and therefore avoids social situations) will learn to “uncouple” the conditioned association between crowds and the fear-response via repeated, prolonged exposure to crowds/strangers in realistically safe settings (malls, parks, restaurants, etc.). In addition, many trauma survivors with PTSD find the physiological symptoms associated with the disorder highly distressing themselves (e.g., increased heart rate, sweating, shortness of breath, etc.). Thus, these visceral stimuli also become targets for exposure therapy (e.g., interoceptive exposure to prescribed exercise). Through repeated exposure to feared stimuli, not only is the conditioned arousal response extinguished (Keane et al., 1985; Kilpatrick et al., 1985), but the survivors also learn to tolerate their symptoms and learn that they can handle their arousal responses.

In addition to the more parsimonious learning theory described above, an alternative cognitive theory that explains the efficacy of exposure is emotional processing, which involves two basic premises (Foa & Kozak, 1985, 1986). The first premise is that PTSD indicates the presence of maladaptive fear structures in the memory of a survivor (see above section for more discussion). The second premise is that successful treatment modifies the maladaptive elements of the fear structure in such a way that information which previously elicited anxiety symptoms no longer does so. According to this theory, when a survivor is intentionally exposed to safe but feared stimuli, they encounter new information that is not compatible with the fear structure. In addition to modifying pathological conditioned responses, the new information is instructive about the probability and cost of feared consequences and disconfirms erroneous beliefs associated with the fear structure (Cahill & Foa, 2007).

Thus, most cognitive-behavioral treatment models include an exposure component which is thought to promote reconditioning and process mechanisms of change. However, the amount and type of exposure that is most beneficial to patients remain controversial and therapies involving only a minimum of “reliving” the trauma have been found to be effective (Ehlers et al., 2003; Ehlers, Clark, Hackmann, McManus, & Fennell, 2005; Harvey, Bryant, & Tarrier, 2003). In addition, some research has suggested that it is not only exposure-based physiological activation and reconditioning that is responsible for fear reduction (Kamphuis & Telch, 2000; Lang & Craske, 2000), but rather, repeated nonreinforced exposure to feared stimuli results in a completely new memory being formed (Rescorla, 2001). Following this line of thinking, the formation of new memories associated with cognitive change leads to fear reduction (Kindt et al., 2007), but the likelihood of this happening independent of behavioral exposure is low.

Despite the questions remaining surrounding the optimal amounts of exposure or the underlying cognitive mechanisms of impact, the role of exposure to trauma-related cues and stimuli in PTSD symptom change and extinction is well established (Domjan, 2003; Resick, Monson, & Gutner, 2007). As such, exposure and the resulting cognitive/emotional processing and reconditioning are considered primary mechanisms of change in PTSD.

28.5 6.5 Evidence-Supported Treatment Approaches

Based upon the guidelines developed by the Division 12 Task Force on Promotion and Dissemination of Psychological Procedures (1995; Chambless et al., 1996) and the American Psychological Association Task Force on Psychological Intervention (1995), Chambless and Hollon (1998) outlined a definition for ESTs. These criteria are repeatedly discussed throughout the literature and, thus, are described in brief here. The five criteria are: (1) EST must be compared with a control group or alternative treatment in a randomized control trial (RCT) in which the EST is statistically superior to the comparison group; (2) studies of the EST must include a treatment manual, a population with reliable and valid inclusion criteria, reliable and valid outcome assessment measures, and appropriate data analysis; (3) EST must be superior to the comparison treatment in at least two independent research settings with the majority of studies supporting its efficacy. If only one study is available, in the absence of conflicting evidence, the label of “possibly efficacious” is assigned. The label of “efficacious and specific” is used if the EST is shown to be superior to an alternative treatment, including pill or psychological placebo, in at least two independent research settings.

Similar guidelines have been adopted for PTSD treatments (Foa & Meadows, 1997; Harvey et al., 2003). The ESTs for PTSD include exposure therapy (Foa, Rothbaum, Riggs, & Murdock, 1991; Rothbaum & Foa, 1992), eye movement desensitization and reprocessing (EMDR; Shapiro, 1989, 1995), stress inoculation therapy (SIT; Kilpatrick & Amick, 1985; Kilpatrick, Veronen, & Resick, 1982), cognitive therapy or cognitive processing therapy (CPT; Resick, 1992; Resick & Schnicke, 1992, 1993), and various pharmacological agents (for review, see Friedman & Davidson, 2007). The descriptions for each of the treatments are provided below.

28.5.1 6.5.1 Evidence-Supported Treatments

Exposure Therapy. Exposure therapy is the most thoroughly investigated form of treatment for PTSD and is found in several different variations, including systematic desensitization, flooding, prolonged exposure, or implosive therapy (Keane & Barlow, 2002). Importantly, most of the effective types of treatment for PTSD involve an exposure therapy component, including EMDR, SIT, and CPT. Exposure therapy techniques involve confronting (in realistically safe environments) one’s feared persons, places, situations, and/or memories through in vivo exposure and imaginal exposure (Keane & Barlow, 2002; Resick & Calhoun, 2001). Evidence supports the efficacy of exposure therapy alone (Foa et al., 1999; Ironson, Freund, Strauss, & Williams, 2002; Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998; Resick, Nishith, Weaver, Astin, & Feuer, 2002) and in combination with other treatments (Foa et al., 1999; Lee, Gavriel, Drummond, Richards, & Greenwald, 2002; Marks et al., 1998) in comparison to wait-list control. Comparisons studies demonstrate that exposure therapy also is more efficacious than several active treatments, including SIT (Foa et al., 1991, 1999) and relaxation therapy (Taylor et al., 2003). In fact, dismantling studies that have been conducted to determine active ingredients responsible for PTSD treatment gains demonstrate that exposure in isolation is as effective as several variations of combination treatments (Foa et al., 2005; Paunovic & Öst, 2001).

Eye Movement Desensitization and Reprocessing. Eye movement desensitization and reprocessing is a controversial, but effective, treatment developed through personal observation rather than an empirical procedure (Keane & Barlow, 2002; Resick & Calhoun, 2001). The premise of EMDR is that troubling thoughts and imagines can be resolved through lateral eye movements. Thus, the basic EMDR protocol for PTSD involves: (1) visualizing the traumatic memory (i.e., imaginal exposure); (2) rehearsing the negative cognitions (i.e., cognitive exposure); (3) focusing on the physical symptoms of the anxiety (i.e., visceral exposure); and (4) engaging in bilateral eye movements by following the clinician’s finger back and forth for 24 repetitions (Resick & Calhoun, 2001). The controversy centers over whether or not the eye-movements are actually necessary or add anything to the efficacy of the treatment. Although the majority of the early research was limited to case studies and noncontrolled studies (Resick & Calhoun, 2001), more recent investigations repeatedly have demonstrated the efficacy of the EMDR in patients with PTSD (for review, see Resick et al., 2007). In fact, several studies have found no differences on similar outcome measures between the efficacy of EMDR and exposure therapy at posttreatment and follow-up (e.g., Ironson et al., 2002; Lee et al., 2002; Power et al., 2002; Rothbaum, Astin, & Marsteller, 2005). However, studies of EMDR with and without the eye movements demonstrated equal effectiveness (Boudewyns & Hyer, 1996; Devilly, Spence, & Rapee, 1998; Pittman, Orr, Altman, & Longpre, 1996), suggesting that the active mechanism of EMDR is the exposure to, and perhaps the “processing” of, traumatic memories, rather than the bilateral eye movements (Keane & Barlow, 2002; Resick & Calhoun, 2001). As such, the treatment adds little to existing behavioral and cognitive treatments. In commenting on EMDR in light of these findings, McNally (1999) noted “what is effective in EMDR is not new, and what is new is not effective” (p. 619).

Stress Inoculation Therapy. Stress inoculation therapy (Kilpatrick & Amick, 1985; Kilpatrick et al., 1982) was one of the first comprehensive treatments for PTSD (Resick & Calhoun, 2001). SIT emphasizes an individually tailored treatment program to instruct patients in a set of coping skills which in turn facilitate mastery over their fears. SIT contains multiple treatment components, including psychoeducation, muscle relaxation, breathing control, covert modeling, role playing, thought stopping, and guided self-dialogue. Several studies have supported the efficacy of SIT when compared to a wait-list control group (Foa et al., 1991, 1999); however, as described earlier, SIT and SIT with exposure appear to perform worse than exposure-alone (Foa et al., 1999), perhaps because of the fewer overall exposure trials and less overall focus on therapeutic exposure in SIT.

Cognitive Therapy. Based upon the information-processing theory of PTSD (Foa & Kozak, 1986; Foa et al., 1989), CPT was specifically designed to combine components from exposure-based treatment of PTSD with cognitive components from standard cognitive therapy (Resick & Calhoun, 2001). The cognitive components of CPT target the conflicting beliefs and meanings attributed to the traumatic event and expectations about the future. The exposure component involves creating an exposure narrative of the sensory memories, thoughts, and feelings during the traumatic event and reading the narrative daily throughout treatment. Several studies support CPT’s efficacy over wait-list control groups (Chard, 2005; Monson et al., 2006; Resick & Schnicke, 1992) and show CPT to be equally efficacious as prolonged exposure (Resick et al., 2002). It is difficult to determine, however, based on existing studies, whether CPT would remain as efficacious as prolonged exposure if its exposure components were removed.

Pharmacotherapy. Several antidepressants appear useful in treating PTSD. These agents include selective serotonin reuptake inhibitors (SSRIs; Brady et al., 2000; Davidson et al., 2001; Marshall, Beebe, Oldham, & Zaninelli, 2001; Tucker et al., 2001), tricyclic antidepressants (TCAs; Davidson et al., 1990; Kosten, Frank, Dan, McDougle, & Giller, 1991), monoamine oxidase inhibitors (Kosten et al., 1991; Neal, Shapland, & Fox, 1997), and several other antidepressant agents including nefazodone (Saygin, Sungur, Sabol, & Cetinkaya, 2002), mirtazapine (Davidson et al., 2003), and venlafaxine (Davidson et al., 2006). Several other types of medications also have shown promise in the treatment of PTSD, including antiadrenergic agents, anticonvulsant agents, partial N-methyl-D-aspartic acid (NMDA) agonists, gamma-Aminobutyric acid-ergic (GABA-ergic) agonists, and atypical antipsychotics; however, more research is needed to determine their efficacy (Friedman & Davidson, 2007). In general, although several concerns still exist regarding the generalizability to different populations and the maintenance of treatment effects after the discontinuation of the medication (Friedman & Davidson), SSRIs are considered the pharmacological treatment of choice based upon mounting support for their efficacy in the literature and their relatively mild side effects (American Psychiatry Association, 2004; Davidson et al., 2005). Note, however, that pharmacologically based improvements in PTSD symptomatology, while statistically significant and reliability reported, rarely result in complete, or even nearly complete symptom amelioration (Albucher & Liberzon, 2002).

28.5.2 6.5.2 Selecting Which Treatment to Use

Based on the findings presented above, there are numerous psychosocial and pharmacological treatment options for PTSD. Although it may appear that some of the active treatments outperform others in direct comparison studies and meta-analytic investigations (e.g., Bisson et al., 2007; Foa et al., 1999; Taylor et al., 2003), the small number of comparison studies combined with variations in samples, measures, and treatment procedures between studies suggest that any conclusions may be a result of numerous confounds (Benish, Imel, & Wampold, 2008; Shadish & Sweeny, 1991). In fact, in the majority of treatment studies, the comparison therapies were not intended to be actively therapeutic (e.g., supportive therapy), which, similar to placebo-controlled studies with medications, may artificially inflate the benefits of the active treatments (Benish et al., 2008). In order to address these concerns, Benish et al. completed a meta-analysis of only bona fide psychosocial treatments and found no evidence of outcome differences in PTSD symptoms or any other outcome variable, suggesting that previously reported differences among treatments may be accounted for by methodological differences. Alternatively, the centrality of the exposure component to most existing treatments may indicate that this is the “active ingredient” in effective interventions for the disorder. Given these possibilities and their implications regarding the lack of importance of specific treatment components (i.e., other than exposure), treatment choice among the ESTs should be based upon other factors, including clinician experience and preference and, most importantly, the “fit” between a particular intervention and a particular patient. For example, a cognitively advanced patient may feel well matched to CPT; whereas, a very highly motivated patient with moderate- to low-anxiety sensitivity may prefer prolonged exposure. Such matching of patient preferences to intervention characteristics may well enhance patient satisfaction and adherence (Benish et al., 2008). However, notwithstanding these potentially useful treatment components, clinicians should not lose sight of the central importance of exposure in any intervention for PTSD.

28.5.3 6.5.3 Limitations and Future Directions

Although several ESTs are available, a number of questions still exist regarding how best to treat patients with PTSD. In order to address these questions, future directions for the PTSD literature include: increasing the number of methodologically sound RCTs, comparison studies of active treatments, and dismantling studies to determine which components are most important to the treatment of PTSD (Benish et al., 2008; Resick et al., 2007); examining each of the ESTs in a wide range of at-risk populations including victims of interpersonal violence, disasters, military combat personnel, and emergency service responders (Harvey et al., 2003); increasing the amount of research on the prevention of PTSD and the treatment of acute posttraumatic reactions (Friedman & Davidson, 2007; Litz & Maguen, 2007); broadening current ESTs for PTSD to treat comorbid conditions such as substance abuse and/or depression (Resick et al., 2007); disseminating the ESTs to increase treatment access for patients with PTSD (Resick et al., 2007); and, risk, recovery, and resiliency studies, including genetic studies, to determine what types of individuals are most likely to develop PTSD, recover, or never experience symptoms in order to refine treatment strategies and to direct them to those at greatest risk. Together, these future directions may aid in improving the ESTs for PTSD and the quality of care of patients with PTSD. Basic Competencies of the Clinician

Mastery of the clinical competencies of psychotherapy is vital to administering any and all forms of psychosocial treatments effectively (Sumerall, Lopez, & Oehlert, 2000; Zaro, Barach, Nedelman, & Dreiblatt, 1977). Thus, a number of education and training programs have developed competency-based training models, including the National Council of Schools and Programs of Professional Psychology (Peterson, Peterson, Abrams, & Stricker, 1997), scientist-practitioner clinical psychologists (Belar, 1992), counseling psychologists (Stoltenberg et al., 2000), and the Association of Directors of Psychology Training Clinics (Hatcher & Dudley Lassiter, 2006). In fact, a separate section on competence was added to the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct (American Psychological Association, 2002). Together, these events demonstrate an escalating interest in competency-based education, training, and credentialing in psychology (Kaslow, 2004; Sumerall et al., 2000).

Competence is defined as “the habitual and judicious use of communications, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served” (Epstein & Hundert, 2002, p. 227). More specific to psychotherapeutic competencies, there is a set of core (or basic) and specialty (or expert) competencies that is required to be an effective therapist (Kaslow, 2004). As outlined by Spruill et al. (2004), the basic competencies include: intervention planning (i.e., integration of theory, research and practice, assessment, case formulation, and selection of the best strategy for intervention); intervention implementation (i.e., execution of the treatment plan, management of special situations, termination skills, working with and within various care systems, general case-management abilities, and self-care); and intervention evaluation (i.e., performance appraisal/self-evaluation skills and effective use of supervision and consultation). The expert competencies go a step further by building upon the core competencies through the application of advanced practices that require specialized knowledge, skills, and attitudes (Kaslow, 2004).

In the sections that follow, we adapt these notions of basic and expert competencies to the treatment of PTSD. As described earlier, most effective behavioral interventions for PTSD involve a form of exposure therapy (Resick et al., 2007). Thus, the competencies described below pertain to the skills needed to administer efficacious exposure therapy to patients with PTSD. As treatment protocols of exposure-oriented therapies are available elsewhere (e.g., Foa, Hembree, & Rothbaum, 2007; Foa & Rothbaum, 1998), these sections will focus on the competencies involved in successfully employing these treatments, rather than step-by-step descriptions of treatment procedures and/or scripts of sample dialogues.

Similar to the standard clinical competencies, the basic skills in employing effective exposure therapy with patients with PTSD involve both specific and nonspecific therapeutic factors. Nonspecific factors involve relationship building skills, including warmth, empathy, reflective listening, and positive regard (Lejuez & Hopko, 2006; Strupp & Hadley, 1979). Specific factors refer to the particular intervention-based techniques that target, disrupt, or otherwise change maladaptive or pathological processes. Research on these factors has demonstrated a link between the nonspecific factors (Orlinsky, Ronnestad, &Willutski, 2004) and specific factors (Bemish et al., 2008) with treatment outcome across a variety of treatment modalities. Based upon the PTSD treatment literature (Foa et al., 2007), we selected three primary competencies to discuss: building a therapeutic relationship, conveying the rationale for treatment, and encouraging treatment adherence.

Relationship Building. Similar to most forms of psychotherapy, a strong therapeutic alliance is a critical component to the efficacious treatment of PTSD (Foa et al., 2007). Thus, a number of skills are needed to promote the development of a trusting therapist–patient relationship. However, as detailed below, some of these skills must be adapted to the specific needs of patients with PTSD. These skills include acknowledging a patient’s decision to enter treatment, remaining nonjudgmental, restricting one’s own expressions of affect, incorporating a patient’s experiences into the descriptions of treatment, and being confident and collaborative in one’s approach to treatment. Together, these competencies of relationship building will promote a trusting therapeutic alliance with patients with PTSD.

When initially developing a relationship with a patient, the therapist should acknowledge and support a patient’s decision for entering into the therapeutic process. This initial step toward getting help can be a major turning point in a patient’s well-being and psychological health and deserves the therapist’s attention and positive reinforcement in light of the fact that simply presenting for treatment initially can be highly aversive. In addition, several types of PTSD patients (e.g., victims of sexual assault and active military personnel) may have been discouraged or made to feel guilty about seeking treatment. Thus, therapists must align themselves with the patient to support his or her efforts for treatment. Checks of motivation and frequent use of positive reinforcement should be maintained throughout the treatment experience, especially during transitions in treatment procedures and periods of increased avoidance (Foa et al., 2007).

A second component of relationship building involves the ability to be nonjudgmental and comfortable with the details of a patient’s traumatic experiences. In particular, a therapist must be able to communicate with a patient without expressing verbal or nonverbal affect indicative of shock, disgust, incredulousness, anger, or sadness. Although this competency may seem straightforward, a combination of basic socialized responses and clinical training to both empathize and express sympathy can present subtle, though important, obstacles to developing this competency. It is very important that therapists allow their patients the space to describe their experiences and emotions by limiting their own expressions of sympathy or empathy, at least during the initial recounting of the story. Normal and natural displays of sympathy upon hearing a traumatic story, such as empathetically wincing or offering hasty condolences are not only unhelpful, but often can also be counterproductive. Therapists should strive for a balance by not overtly expressing high levels of empathy considered normal in other forms of therapy, but also not acting cold or indifferent to the patient’s emotional recount of their traumatic event. However, once a desirable balance is found, open communication with the patient will promote a healthy therapeutic relationship.

There are several reasons for therapists to restrict their immediate expressions of affect or empathy. First, when a therapist avoids expressing overt signals of distress, they model hearing about an awful traumatic event without experiencing overt distressing emotions, challenging a patient’s common intrinsic assumption that traumatic events are inexorably related to uncontrollable negative emotions. Second, as traumatic events often are reexperienced in jagged, disorganized, and tangled packets of memories and emotions (Foa & Kozak, 1991), it is often difficult to guess correctly which details of the trauma are related to which emotions. By automatically empathizing with assumed emotions, a therapist risks misunderstanding and invalidation. A third reason for limiting the reactive flow of verbal and nonverbal affect or empathy is that it may promote the projection of thoughts and feelings belonging to the therapist onto the patient. This expression of emotions by a therapist, sometimes labeled countertransference, is associated with a negative impact on behavioral treatment outcomes (Ellis, 2001).

Another component of relationship building involves the retention and use of a patient’s own descriptions of their fears in the therapeutic examples of psychoeducation and treatment rationale. For example, a therapist may choose to demonstrate the connection between a patient’s specific set of avoidant behaviors (e.g., avoiding crowded areas) and the negative impact on their social or occupational functioning (e.g., cannot retain a fulltime job). This skill can accomplish several goals for developing a trusting therapeutic relationship. First and foremost, the use of a patient’s own example of fears and symptoms demonstrates to the patients that they are heard and understood. Second, the incorporation of their descriptions into the therapeutic examples may promote greater understanding of the rationale for treatment. Finally, this act of adaptation to the psychoeducation and treatment rationale demonstrates that the therapist is tailoring treatment to the patient’s individual needs.

A fourth component of relationship building with patients with PTSD involves the ability to instill hope in patients and confidence in the treatment modality through a flexible and collaborative therapeutic process. PTSD treatment often requires a large emotional commitment due to its anxiety-provoking nature. Thus, it is possible that there may be little positive reinforcement for a patient to continue treatment prior to the recognition of symptom reductions. During this period, several extrinsic reinforcers may be motivating a patient to remain in treatment, including support from family and friends and the patient’s initial relationship with the therapist; however, these factors may not be long lasting if the patient does not believe that the treatment will work. In order to instill hope and confidence in the patient, a therapist must be able to sell themselves and the therapy by demonstrating their own knowledge and expertise about PTSD and its treatment. In addition, a therapist also must be collaborative with a patient’s individual goals and needs to encourage their active participation while monitoring and adapting to the patient’s anxiety and urges to avoid. Accordingly, a basic competency for all forms of exposure therapy is the capacity to instill confidence in patient’s ability to get better. Together, these practices may aid in the development of hope and confidence in the patient and a strong therapeutic alliance with the therapist, likely improving treatment adherence, attendance, and homework completion.

Conveying the Treatment Model. A second basic competency of employing exposure-oriented therapies is the therapist’s ability to clearly, effectively, and convincingly convey the treatment model to patients with varying levels of sophistication. Although most effective behavioral treatments for PTSD involve talking about, dealing with, or imagining the traumatic event, the vast majority of exposure exercises take place outside of the treatment center and outside the eyesight of the therapist (Foa et al., 2007). Accordingly, it is imperative to the success of treatment that a patient understands and appreciates the benefits associated with exposure and, thus, be willing to engage in these activities on their own. This may be particularly challenging in patients with PTSD due to their reliance on avoidance as a method to reduce anxiety and distress (Friedman et al., 2007). Much of the treatment rationale must be presented through early psychoeducation about the disorder and the treatment for the disorder.

Psychoeducation about the symptoms and treatments of PTSD can be challenging to deliver due to the complexity of the disorder. Some common psychoeducation topics include a basic explanation of the origins of intrusive memories and nightmares, the fight or flight response, thought suppression, and explanation of the role of negative reinforcement in escape and avoidant behaviors. Therapists should be well versed in, and comfortable with, using several explanations and metaphors to be effective in conveying the information to patients. In addition, as described earlier, it is helpful to incorporate the patient’s own symptoms and experiences into the psychoeducation to improve understanding of the descriptions. The primary goals of psychoeducation are to present a convincing rationale for treatment and have the patient buy into the treatment procedures. These goals can be accomplished by remaining thoroughly grounded in the conceptual model and theory underlying exposure therapy (Foa et al., 2007). The addition of research findings and the therapist’s own experiences administering exposure therapy may aid in the process. Finally, as an example of these concepts, Foa et al. recommend telling patients, “that we will push them outside of their comfort zone but not outside of their safety zone” (p. 33). Together, these practices should increase the patient’s understanding of the rationale for treatment and further develop the therapeutic alliance and, likely, decrease the treatment attrition.

Encouraging Treatment Adherence. A third basic competency of employing exposure-oriented therapies is encouraging treatment adherence through the control of patient avoidance. Treating PTSD effectively is analogous to treating avoidance effectively. This sentiment cannot be overstated. Although attrition rates for exposure-based and nonexposure-based treatments are similar (Hembree et al., 2003), roughly 20–30% of all patients with PTSD end treatment prematurely. Thus, specific techniques should be used to help reduce attrition rates and avoidance and increase the likelihood of successful treatment.

One technique to improve treatment adherence is to help patients plan for anticipated avoidance. Engage the patient in direct discussions regarding the notion of the avoidance of treatment. Preparing for common avoidance reactions (e.g., I did not sleep well the night before), especially early on in the treatment process, can help patients to overcome their avoidance and attend treatment regularly. For less cognitively sophisticated patients or adolescents, it can be productive to create a name for their avoidance (e.g., “Avoiding John” or “Mr. Avoider”) to externalize the symptoms and promote greater awareness of their avoidant tendencies.

A second technique to reduce in-session avoidance is to help patients to identify their sidetracking techniques. More specifically, patients may arrive to therapy motivated to talk about the “emergency of the week,” rather than the assigned homework and prescribed in session exercises. Although these attempts are often sincere, they also are powerful avoidant strategies. One approach to prevent these distractions may be to outline the agenda at the beginning of each session and allocate a brief period for discussion of the past week’s events (e.g., 5 min). In addition, another strategy may be to ask at the beginning of each session, “how was your homework?” rather than, “how was your week?” to orient the patient to an agenda item, rather than a distraction.

A third technique to reduce patient avoidance is to make reminder calls for appointments and homework assignments prior to the upcoming session. These reminder calls may help patients to stay oriented toward nonavoidance and provide opportunities for additional positive reinforcement from the therapist. Although potentially time-consuming, reminder phone calls, especially early on in treatment, can help to reduce patient avoidance of treatment sessions and homework assignments, thus, improving the likelihood of efficacious treatment. Expert Competencies of the Clinician

Given the development of basic competencies in treating PTSD, therapists continuing to treat PTSD naturally may gravitate toward expert competencies. These expert competencies build upon basic competencies through the application of advanced practices that require specialized knowledge, skills, and attitudes of the targeted population and specific treatment procedures (Kaslow, 2004). Many EST protocols include room for flexibility to allow for the individual expression of expert therapist competencies within the therapeutic framework (Foa et al., 2007; Kendall, Chu, & Gifford, 1998; Lejuez & Hopko, 2006). Detailed below are three techniques that we have deemed as expert competencies necessary to the treatment of PTSD, including treating co-occurring conditions, using creativity and flexibility in the development of exposure exercises, and crisis management.

Treating Co-occurring Conditions. Similar to patients with other anxiety disorders and depression, patients with PTSD frequently present with comorbid or co-occurring conditions, including high rates of major depressive episodes (48%; 49%), specific phobias (31%; 29%), social phobia (28%; 28%), alcohol abuse/dependence (52%; 28%), drug abuse/dependence (36%; 27%), and generalized anxiety disorder (17%; 15%) in men and women, respectively (Kessler et al., 1995). Thus, one expert competency in the treatment of PTSD involves the incorporation of additional skills and resources from the other EST modalities. These additions to standard EST practices for PTSD may aid in addressing the complex needs of patients with comorbid conditions. For example, some patients with PTSD may be particularly sensitive to the somatic symptoms associated with PTSD or related anxiety disorder. If these sensitivities result in additional distress or avoidance, it may be beneficial to incorporate aspects of interoceptive exposure exercises (Barlow, Craske, Cerny, & Klosko, 1989). These exercises incorporate physical activities, like jogging-in-place or spinning in a chair, to expose patients to the physiological symptoms of anxiety in a safe environment while encouraging habituation and the extinction of these fears. Additional treatments, including exposure with response prevention for obsessive thoughts and compulsive behaviors (Foa & Wilson, 1991), motivational interviewing for substance use disorders (Miller & Rollnick, 2002), and behavioral activation for depression (Lejuez, Hopko, Lepage, Hopko, & McNeil, 2001), may expand the scope of treatment and improve treatment outcome. The ability to identify broader behavioral concepts and appropriately intervene can be more important than closely following any specific treatment protocol, especially if these changes address the needs of the patient. These practices depend on the use of therapist creativity, flexibility, and ability to create an individual treatment plan for the patient (Kendall et al., 1998). While these and other adjunctive treatment techniques can be helpful, one must take care to provide such interventions in addition to, and not at the expense of, time devoted to exposure-oriented techniques (Foa, Rothbaum, & Furr, 2003). Preliminary research on the treatment of comorbid PTSD and panic disorder and PTSD and substance use disorders has demonstrated promising findings (for review, see Resick et al., 2007).

Using Creativity in Conducting Exposure Exercises. Another expert competency in the treatment of PTSD involves the use of creativity in designing exposure exercises. Creative practices can be applied to both in vivo and imaginal exposure exercises as long as the therapist adheres to the recommended guidelines for exposures. As outlined by Antony and Swinson (2000), the guidelines for conducting an exposure involve: practicing exposures in a planned, structured, and predictable fashion; presenting the exposures at a gradual pace; practicing exposures without subtle avoidance strategies; rating patient levels of fear during the exposure; attempting not to fight the fear during an exposure exercise; practicing exposure exercises frequently and close together; practicing exposure exercises long enough to experience a significant decrease in anxiety; using cognitive coping strategies to counter anxious automatic thoughts during exposure practice; and expecting to feel uncomfortable during the exposure. However, these guidelines provide room for interpretation of, and flexibility in, the exposure practices.

Several examples of uses of creativity in exposures are as follows. In vivo exposures may include the use of actors, props, or technology to increase the level of realism of the exposure exercise. For example, recent developments in virtual reality (VR) exposure practices have demonstrated promising results in patients with PTSD (for review, see Welch & Rothbaum, 2007). These VR simulations include accurate visual, auditory, and even tactile and olfactory cues from the initial traumatic event (e.g., driving armored convoy through Iraq). Creativity also can be adapted to imaginal exposure exercises to help patients to experience their memories in a vivid and sensory-rich manner. All five of the senses should be used in exposure exercises to promote the development of movie-like imagery of the traumatic memories, including cues for the sights, sounds, tastes, smells, and physical sensations. Being creative and vivid with questioning also sends a message to the patient that mastery of all aspects of the memory is vital to, and attainable in, the treatment of PTSD. These creative exercises should carry over into the patient’s behavioral homework assignments. The use of audio/video clips, images, driving routes, times of day, or even the weather conditions may help create opportunities to alter and adapt exposure practices to individual patient needs.

Crisis Management. Given the presentation of patients with severe PTSD and the nature of exposure therapy, crisis management skills frequently are needed to maintain order in session and keep the focus on the treatment of PTSD (Foa et al., 2007). Sources of potential crises include comorbid conditions and related suicidality (e.g., depression, substance use, borderline personality disorder), multiple life stressors that lead to chaotic lifestyles and interfere with the development of healthy coping strategies (e.g., social, familial, or financial troubles), and over-engagement or excessive emotional distress elicited by an exposure exercise (e.g., dissociative symptoms or emotionally overwhelmed). Several techniques should be used for crisis management. First, if a patient is over-engaging in an exposure exercise, the exposure procedures should be reversed to reduce immediate distress, but maintain the focus of treatment. For example, in imaginal exposure, a patient may describe the exposure scene in the past tense, rather than the present tense, or keep their eyes open, rather than closed, to slightly reduce the engagement of the exposure exercise and reduce the associated distress. Second, if comorbid conditions or additional problem areas are identified during the initial assessment, frequent reassessments should be conducted throughout the treatment to monitor progress (e.g., amount of alcohol consumption). If the additional problems are deemed an immediate risk to the safety of the patient, PTSD treatment should be postponed. However, if no imminent risk is identified, treatment should continue in order to improve the anxiety and distress associated with PTSD and, hopefully, also positively impact the comorbid condition (Foa et al., 2007). Once again, the focus of treatment should remain on improving PTSD; however, crisis management skills are a vital expert competency in the treatment of PTSD. Transition from Basic Competence to Expert Competence

Competency-based education focuses on the development of the therapist into an independent, ethical, and effective clinician in a specific, specialty area of psychotherapy (Kaslow, 2004). These goals typically are predetermined and clearly outlined by a governing body or professional society; however, these requirements should not be limited to the acquisition of specified competencies, rather these qualities should emphasize the ability to adapt to change, exhibit sound judgment in challenging situations with conflicting values and ethical issues, generate new knowledge, and continue to learn and improve performance (Fraser & Greenhalgh, 2001).

When these training issues are related to the transition from the basic to expert competencies, several important considerations must be evaluated, including therapist experience, supervision and collaboration opportunities, and the availability of, and exposure to, an eclectic mix of patients and presenting problems. As in any competency-based education, training should be developmentally informed, thereby incorporating increasingly more complicated experiences (Kaslow, 2004). For example, many of the basic competencies can be accomplished through initial assessment interviews with patients with PTSD. Within each interview, a therapist may practice relationship building and conveying the treatment model in a safe, less-intimidating setting. Once mastered in an assessment setting, new treatment patients with uncomplicated presentations of PTSD should be assigned, allowing the therapist to master each of the basic competencies within a treatment setting. Once again, after mastery is accomplished, patients with complicated presentations of PTSD (e.g., patients with comorbid disorders, patients with extreme distress, and patients with severe avoidance) should be assigned to practice the expert competencies. In cases where therapists have minimal prior patient contact, PTSD vignettes should be used to role play therapeutic interactions and practice exposure exercises. Of course, each of these steps should be supervised by an expert in the field of PTSD treatment and occur within a respectful and facilitative learning environment to ensure that acceptable levels of knowledge and skills are developed (Kaslow, 2004). Conclusion

Together, these basic and expert competencies represent a set of skills necessary for the efficacious treatment of PTSD. Although similar to the standard practices for beginning and expert therapists (Kaslow, 2004), these practices are modified to recognize the specific challenges of working with patients with PTSD. Thus, each competency requires additional attention, training, and supervision to achieve mastery.

28.6 6.6 Summary

From its initial definition and frequent revisions in the DSM, the assessment and treatment of PTSD has presented many challenges to clinicians and researchers alike. However, through advances in cognitive and behavioral theory and practice (e.g., Cahill & Foa, 2007; Foa & Kozak, 1986), a number of ESTs has been developed to successfully treat PTSD (Resick et al., 2007). Although the precise mechanisms of change are still uncertain (Benish et al., 2008), both basic- and expert-level clinician competencies, including developing a trusting relationship with appropriate empathy and reflective listening, delivering therapeutic techniques like exposure comfortably and confidently, and applying creativity and flexibility to meet the patient’s needs, are common requirements for each of the ESTs. In combination with supervision and collaboration with other experts and awareness of the ever-changing literature, evidence-supported therapeutic practices can be administered competently and effectively to patients with PTSD and related disorders.

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