For clinicians, global treatment issues often begin with answering the question, “Why seek help now?” and proceed to determining what issues or situations may delay or alter a typical PTSD treatment approach.

When creating a treatment plan for someone with PTSD, there are a number of factors to consider, including the following:

Many treatments for PTSD encourage the patient to specifically remember and focus on the experienced trauma (e.g., “trauma-focused” treatment). Others encourage the patient to increase coping skills for current here-and-now stressors to improve daily functioning and decrease PTSD symptoms (e.g., “supportive therapy”). Sometimes, either psychotherapeutic approach is combined with medication. And sometimes, comorbid disorders must be treated before PTSD treatment can begin.

Trauma-focused therapy uses the in-depth exploration of traumatic material to facilitate healing. It can be conducted in individual or group contexts with techniques that vary from cognitive behavioral therapy (CBT) [3] to psychodynamic approaches [4, 5]. CBT approaches focus on patterns of reinforcement, learning and conditioning models, and correcting erroneous cognitions. In contrast, psychodynamic approaches focus on unconscious and conscious motivations and drives. Current evidence is much stronger for CBT than for psychodynamic treatment. The goal of both approaches to trauma-focused therapy is for patients to take control of their lives by gaining authority over traumatic memories in order to control PTSD-related thoughts, feelings, and behaviors.

CBT and other treatment approaches are discussed in Chap. 4 , pages XX–YY.

Trauma-focused treatment may not be beneficial for everyone. Most research data on trauma-focused treatments apply only to those patients who have agreed to undergo such treatment. Scientific evidence shows that trauma-focused CBT treatments (such as prolonged exposure [PE] and cognitive processing therapy [CPT]) have proven to be the most effective treatments to date. Eye movement desensitization and reprocessing (EMDR) is another trauma-focused approach in which the patient does not have to verbally recount the traumatic experience but is instructed to focus on such memories (see Chap. 4). Despite the proven efficacy of these approaches, some patients have absolutely no wish to revisit traumatic material because they:

Stress inoculation training (SIT) is an alternative that has not been tested extensively. It is an evidence-based treatment that compares favorably with effective trauma-focused approaches but that does not require the patient to recall painful traumatic memories. Instead, SIT emphasizes anxiety management skills to enable patients to cope more effectively with current situations that are predictably exacerbated by their PTSD symptoms.

Present-centered therapy (PCT) is another non-focus treatment in which patients are actively discouraged from addressing details of the traumatic event. Instead, they are directed to discuss how their PTSD symptoms are adversely affecting their present lives with respect to marriage, social functioning, work, school, or other important current activities. Research has shown that PCT effectively reduces PTSD symptoms but not as effectively as CBT (e.g., PE therapy).

Acceptance and commitment therapy (ACT) is another non-focus treatment approach that emphasizes “mindfulness” that has been shown to be effective for depression. It is currently being evaluated as a PTSD treatment (see Chap. 4).

Most non-focus PTSD treatments are less structured and do not adhere to a psychotherapy manual as in SIT, PCT, or ACT. What they have in common is that they encourage skill building and problem solving for current issues in the patient’s life as an avenue for increasing adaptive functioning and regaining a sense of control. Supportive treatments that deliberately avoid traumatic material may be beneficial for some with PTSD, although their efficacy has not been shown to exceed that of trauma-focused CBT approaches such as PE and CPT. Currently, there are no guidelines for determining which patients will most likely benefit from one kind of therapy over the other.

The superiority of trauma-focused treatments, especially PE and CPT, has been endorsed by all comprehensive clinical practice guidelines for PTSD treatment that have been developed (e.g., by the International Society for Traumatic Stress Studies, the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, the UK’s National Institute for Health and Clinical Excellence (NICE), the Australian National Health and Medical Research Council (NHMRC), the US Institute of Medicine (IOM), and jointly by the US Departments of Veterans Affairs and Defense (VA/DoD)) [6–11].

Psychosocial treatments discussed in Chap. 4 are the following:

Clinicians often combine treatment methods. For example, medication combined with individual psychotherapy treatment may not only ameliorate psychobiological abnormalities associated with PTSD but also sufficiently reduce symptoms so patients can participate in trauma-focused treatment. Some patients receive individual treatment plus marital, family, or group therapy, while others may take medication as well.

Unfortunately, there are very few published studies in which combined therapy is compared with either psychotherapy or pharmacotherapy alone. One study indicates that among medication partial responders, outcomes improve significantly when prolonged exposure is later added to medication [12]. On the other hand, adding medication to CBT partial responders did not improve clinical outcomes [13]. Another study suggests that the effectiveness of PE could be enhanced if it were combined with the medication D-cycloserine (see Chap. 5) [14].

Pharmacotherapy, in which patients receive medications to help manage PTSD symptoms, is covered in detail in Chap. 5 .

When considering combined treatment, however, it is important to be selective and to recognize that many patients do not need more than one form of treatment at any one time [15]. Good clinical practice requires introducing only one therapeutic approach at a time and carefully gauging its effectiveness before combining it with another.

Most patients with PTSD will have at least one comorbid psychiatric disorder; therefore, the treatment approach should seek to ameliorate both PTSD and the comorbid disorder(s), if possible.