Evidence Based Treatments
Below are some suggested studies and references that may assist you in working with trauma-affected veterans. Wherever “($)” appears, the resource is available commercially at the link provided. To access the study, click on the title and it will take you to the PDF (when available) or the site where the study may be reviewed or purchased.
This compilation of research and references is a work in progress -- suggestions for additions to this page are always welcome and may be sent to firstname.lastname@example.org
Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y., Weeks, W. B., & Friedman, M. J. (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. Journal of Clinical Psychiatry, 74(6), e541-e550. doi:http://dx.doi.org/10.4088/JCP.12r08225
OBJECTIVE: PTSD is an important mental health issue in terms of the number of people affected and the morbidity and functional impairment associated with the disorder. The purpose of this study was to examine the efficacy of all treatments for PTSD. DATA SOURCES: PubMed, MEDLINE, PILOTS, and PsycINFO databases were searched for randomized controlled clinical trials of any treatment for PTSD in adults published between January 1, 1980, and April 1, 2012, and written in the English language. The following search terms were used: "post-traumatic stress disorders", "posttraumatic stress disorder", "PTSD", "combat disorders", and "stress disorders, post-traumatic". STUDY SELECTION: Articles selected were those in which all subjects were adults with a diagnosis of PTSD based on DSM criteria and a valid PTSD symptom measure was reported. Other study characteristics were systematically collected. The sample consisted of 137 treatment comparisons drawn from 112 studies. RESULTS: Effective psychotherapies included cognitive therapy, exposure therapy, and eye movement desensitization and reprocessing (g = 1.63, 1.08, and 1.01, respectively). Effective pharmacotherapies included paroxetine, sertraline, fluoxetine, risperidone, topiramate, and venlafaxine (g = 0.74, 0.41, 0.43, 0.41, 1.20, and 0.48, respectively). For both psychotherapy and medication, studies with more women had larger effects and studies with more veterans had smaller effects. Psychotherapy studies with wait-list controls had larger effects than studies with active control comparisons. CONCLUSIONS: Our findings suggest that patients and providers have a variety of options for choosing an effective treatment for PTSD. Substantial differences in study design and study participant characteristics make identification of a single best treatment difficult. Not all medications or psychotherapies are effective. [Author Abstract]
Walter, K. H., Varkovitzky, R. L., Owens, G. P., Lewis, J., & Chard, K. M. (2014). Cognitive processing therapy for veterans with posttraumatic stress disorder: A comparison between outpatient and residential treatment. Journal of Consulting and Clinical Psychology, 82(4), 551-561. doi:http://dx.doi.org/10.1037/a0037075
OBJECTIVE: Across the Veterans Affairs (VA) Healthcare System, outpatient and residential posttraumatic stress disorder (PTSD) treatment programs are available to veterans of all ages and both genders; however, no research to date has compared these treatment options. This study compared veterans who received outpatient (n = 514) to those who received residential treatment (n = 478) within a VA specialty clinic on demographic and pretreatment symptom variables. Further, the study examined pre- to posttreatment symptom trajectories across the treatment programs. METHOD: All 992 veterans met diagnostic criteria for PTSD and attended at least 1 session of cognitive processing therapy (CPT) in either the outpatient or residential program. Bivariate analyses were utilized to investigate differences between samples on demographic variables and severity of pretreatment symptoms. Multilevel modeling (MLM) was used to investigate the change in symptomatology between the 2 samples from pre- to posttreatment. RESULTS: Analyses indicated that the samples differed on all demographic and pretreatment symptom variables, with residential patients reporting higher scores on all assessment measures. MLM results demonstrated that symptom scores improved for all veterans across time, with outpatients consistently reporting fewer symptoms at both time points. The time by program interaction was significant for PTSD-related symptom trajectories, but not for the depression-related symptom trajectory. CONCLUSION: This is the 1st study to compare pretreatment characteristics and treatment outcome between veterans receiving outpatient and residential PTSD treatment. Findings may help clinicians select appropriate care for their patients by identifying relevant pretreatment characteristics and generally informing expectations of treatment outcome. [Author Abstract]
Jeffreys, M., Reinfeld, C., Nair, P., Garcia, H., Mata-Galan, E., & Rentz, T. (2014). Evaluating treatment of posttraumatic stress disorder with cognitive processing therapy and prolonged exposure therapy in a VHA specialty clinic. Journal Of Anxiety Disorders, 28(1), 108-114. doi:10.1016/j.janxdis.2013.04.010
This retrospective chart review evaluates the effectiveness of manualized cognitive processing therapy (CPT) protocols (individual CPT, CPT group only, and CPT group and individual combined) and manualized prolonged exposure (PE) therapy on veterans' posttraumatic stress disorder (PTSD) symptoms in one Veterans Health Administration (VHA) specialty clinic. A total of 517 charts were reviewed, and analyses included 178 charts for CPT and 85 charts for PE. Results demonstrated CPT and PE to significantly reduce PTSD Checklist (PCL) scores. However, PE was significantly more effective than CPT after controlling for variables of age, service era, and ethnicity. Additional findings included different outcomes among CPT formats, decreased treatment dropouts for older veterans, and no significant differences in outcome between Hispanic and White veterans. Study limitations and future research directions are discussed. (Published by Elsevier Ltd.)
Cook, J. M., Dinnen, S., Thompson, R., Simiola, V., & Schnurr, P. P. (2014). Changes in Implementation of Two Evidence-Based Psychotherapies for PTSD in VA Residential Treatment Programs: A National Investigation. Journal Of Traumatic Stress, 27(2), 137-143. doi:10.1002/jts.21902
There has been little investigation of the natural course of evidence-based treatments (EBTs) over time following the draw-down of initial implementation efforts. Thus, we undertook qualitative interviews with the providers at 38 U.S. Department of Veterans Affairs’ residential treatment programs for posttraumatic stress disorder (PTSD) to understand implementation and adaptation of 2 EBTs, prolonged exposure (PE), and cognitive processing therapy (CPT), at 2 time points over a 4-year period. The number of providers trained in the therapies and level of training improved over time. At baseline, of the 179 providers eligible per VA training requirements, 65 (36.4%) had received VA training in PE and 111 (62.0%) in CPT with 17 (9.5%) completing case consultation or becoming national trainers in both PE and CPT. By follow-up, of the increased number of 190 eligible providers, 87 (45.8%) had received VA training in PE and 135 (71.1%) in CPT, with 69 (36.3%) and 81 (42.6%) achieving certification, respectively. Twenty-two programs (57.9%) reported no change in PE use between baseline and follow-up, whereas 16 (42.1%) reported an increase. Twenty-four (63.2%) programs reported no change in their use of CPT between baseline and follow-up, 12 (31.6%) programs experienced an increase, and 2 (5.2%) programs experienced a decrease in use. A significant number of providers indicated that they made modifications to the manuals (e.g., tailoring, lengthening). Reasons for adaptations are discussed. The need to dedicate time and resources toward the implementation of EBTs is noted.
Wilk, J. E., West, J. C., Duffy, F. F., Herrell, R. K., Rae, D. S., & Hoge, C. W. (2013). Use of Evidence-Based Treatment for Posttraumatic Stress Disorder in Army Behavioral Healthcare. Psychiatry: Interpersonal & Biological Processes, 76(4), 336-348. doi:10.1521/psyc.2013.76.4.336
Objective: To identify the extent to which evidence-based psychotherapy (EBP) and psychopharmacologic treatments for posttraumatic stress disorder (PTSD) are provided to U.S. service members in routine practice, and the degree to which they are consistent with evidence-based treatment guidelines. Method: We surveyed the majority of Army behavioral health providers ( n = 2,310); surveys were obtained from 543 (26%). These clinicians reported clinical data on a total sample of 399 service member patients. Of these patients, 110 (28%) had a reported PTSD diagnosis. Data were weighted to account for sampling design and nonresponses. Results: Army providers reported 86% of patients with PTSD received evidence-based psychotherapy (EBP) for PTSD. As formal training hours in EBPs increased, reported use of EBPs significantly increased. Although EBPs for PTSD were reported to be widely used, clinicians who deliver EBP frequently reported not adhering to all core procedures recommended in treatment manuals; less than half reported using all the manualized core EBP techniques. Conclusions: Further research is necessary to understand why clinicians modify EBP treatments, and what impact this has on treatment outcomes. More data regarding the implications for treatment effectiveness and the role of clinical context, patient preferences, and clinical decision-making in adapting EBPs could help inform training efforts and the ways that these treatments may be better adapted for the military. [ABSTRACT FROM AUTHOR]
Foa, E. B., Yusko, D. A., McLean, C. P., Suvak, M. K., Bux Jr., D. A., Oslin, D., & ... Volpicelli, J. (2013). Concurrent Naltrexone and Prolonged Exposure Therapy for Patients With Comorbid Alcohol Dependence and PTSD A Randomized Clinical Trial. JAMA: Journal Of The American Medical Association, 310(5), 488-495. doi:10.1001/jama.2013.8268
IMPORTANCE Alcohol dependence comorbid with posttraumatic stress disorder (PTSD) has been found to be resistant to treatment. In addition, there is a concern that prolonged exposure therapy for PTSD may exacerbate alcohol use. OBJECTIVE To compare the efficacy of an evidence-based treatment for alcohol dependence (naltrexone) plus an evidence-based treatment for PTSD (prolonged exposure therapy), their combination, and supportive counseling. DESIGN, SETTING, AND PARTICIPANTS A single-blind, randomized clinical trial of 165 participants with PTSD and alcohol dependence conducted at the University of Pennsylvania and the Philadelphia Veterans Administration. Participant enrollment began on February 8, 2001, and ended on June 25,2009. Data collection was completed on August 12,2010. INTERVENTIONS Participants were randomly assigned to (1) prolonged exposure therapy plus naltrexone (100 mg/d), (2) prolonged exposure therapy plus pill placebo, (3) supportive counseling plus naltrexone (100 mg/d), or (4) supportive counseling plus pill placebo. Prolonged exposure therapy was composed of 12 weekly 90-minute sessions followed by 6 biweekly sessions. All participants received supportive counseling. MAIN OUTCOMES AND MEASURES The Timeline Follow-Back Interview and the PTSD Symptom Severity Interview were used to assess the percentage of days drinking alcohol and PTSD severity, respectively, and the Penn Alcohol Craving Scale was used to assess alcohol craving. Independent evaluations occurred prior to treatment (week 0), at posttreatment (week 24), and at 6 months after treatment discontinuation (week 52). RESULTS Participants in all 4 treatment groups had large reductions in the percentage of days drinking (mean change, -63.9% [95% CI, -73.6% to -54.2%] for prolonged exposure therapy plus naltrexone; -63.9% [95% CI, -73.9% to -53.8%] for prolonged exposure therapy plus placebo; -69.9% [95% CI, -78.7% to -61.2%] for supportive counseling plus naltrexone; and -61.0% [95% CI, -68.9% to -53.0%] for supportive counseling plus placebo). However, those who received naltrexone had lower percentages of days drinking than those who received placebo (mean difference, 7.93%; P = .008). There was also a reduction in PTSD symptoms in all 4 groups, but the main effect of prolonged exposure therapy was not statistically significant. Six months after the end of treatment, participants in all 4 groups had increases in percentage of days drinking. However, those in the prolonged exposure therapy plus naltrexone group had the smallest increases. CONCLUSIONS AND RELEVANCE In this study of patients with alcohol dependence and PTSD, naltrexone treatment resulted in a decrease in the percentage of days drinking. Prolonged exposure therapy was not associated with an exacerbation of alcohol use disorder. [ABSTRACT FROM AUTHOR]
Foa, E. B., Gillihan, S. J., & Bryant, R. A. (2013). Challenges and Successes in Dissemination of Evidence-Based Treatments for Posttraumatic Stress: Lessons Learned From Prolonged Exposure Therapy for PTSD. Psychological Science In The Public Interest (Sage Publications Inc.), 14(2), 65-111. doi:10.1177/1529100612468841
Posttraumatic stress disorder (PTSD) poses monumental public health challenges because of its contribution to mental health, physical health, and both interpersonal and social problems. Recent military engagements in Iraq and Afghanistan and the multitude of resulting cases of PTSD have highlighted the public health significance of these conditions. There are now psychological treatments that can effectively treat most individuals with PTSD, including active duty military personnel, veterans, and civilians. We begin by reviewing the effectiveness of these treatments, with a focus on prolonged exposure (PE), a cognitive-behavioral therapy (CBT) for PTSD. Many studies conducted in independent research labs have demonstrated that PE is highly efficacious in treating PTSD across a wide range of trauma types, survivor characteristics, and cultures. Furthermore, therapists without prior CBT experience can readily learn and implement the treatment successfully. Despite the existence of highly effective treatments like PE, the majority of individuals with PTSD receive treatments of unknown efficacy. Thus, it is crucial to identify the barriers and challenges that must be addressed in order to promote the widespread dissemination of effective treatments for PTSD. In this review, we first discuss some of the major challenges, such as a professional culture that often is antagonistic to evidence-based treatments (EBTs), a lack of clinician training in EBTs, limited effectiveness of commonly used dissemination techniques, and the significant cost associated with effective dissemination models. Next, we review local, national, and international efforts to disseminate PE and similar treatments and illustrate the challenges and successes involved in promoting the adoption of EBTs in mental health systems. We then consider ways in which the barriers discussed earlier can be overcome, as well as the difficulties involved in effecting sustained organizational change in mental health systems. We also present examples of efforts to disseminate PE in developing countries and the attendant challenges when mental health systems are severely underdeveloped. Finally, we present future directions for the dissemination of EBTs for PTSD, including the use of newer technologies such as web-based therapy and telemedicine. We conclude by discussing the need for concerted action among multiple interacting systems in order to overcome existing barriers to dissemination and promote widespread access to effective treatment for PTSD. These systems include graduate training programs, government agencies, health insurers, professional organizations, healthcare delivery systems, clinical researchers, and public education systems like the media. Each of these entities can play a major role in reducing the personal suffering and public health burden associated with posttraumatic stress. [ABSTRACT FROM PUBLISHER]
A Congressional Budget Office Study
Yoder, M., Tuerk, P. W., Price, M., Grubaugh, A. L., Strachan, M., Myrick, H., & Acierno, R. (2012). Prolonged exposure therapy for combat-related posttraumatic stress disorder: Comparing outcomes for veterans of different wars. Psychological Services, 9(1), 16-25. doi:10.1037/a0026279
There is significant support for exposure therapy as an effective treatment for posttraumatic stress disorder (PTSD) across a variety of populations, including veterans; however, there is little empirical information regarding how veterans of different war theaters respond to exposure therapy. Accordingly, questions remain regarding therapy effectiveness for treatment of PTSD for veterans of different eras. Such questions have important implications for the dissemination of evidence based treatments, treatment development, and policy. The current study compared treatment outcomes across 112 veterans of the Vietnam War, the first Persian Gulf War, and the wars in Afghanistan and Iraq. All subjects were diagnosed with PTSD and enrolled in Prolonged Exposure (PE) treatment. Veterans from all three groups showed significant improvement in PTSD symptoms, with veterans from Vietnam and Afghanistan/Iraq responding similarly to treatment. Persian Gulf veterans did not respond to treatment at the same rate or to the same degree as veterans from the other two eras. Questions and issues regarding the effectiveness of evidence based treatment for veterans from different eras are discussed. (PsycINFO Database Record (c) 2013 APA, all rights reserved) (journal abstract)
Hawkins, E. J., Grossbard, J., Benbow, J., Nacev, V., & Kivlahan, D. R. (2012). Evidence-based screening, diagnosis, and treatment of substance use disorders among veterans and military service personnel. Military Medicine, 177(8), 29-38.
Substance use disorders (SUDs) are among the most common and costly conditions in veterans and active duty military personnel, adversely affecting their health and occupational and personal functioning. The pervasive burden of SUD has been a continuing concern for the Department of Veterans Affairs (VA) and Department of Defense (DoD), particularly as large numbers of service members return from Operations Enduring and Iraqi Freedom. The VA and DoD have prioritized implementation of evidence - based practices and treatment services to enhance the recognition and management of SUD in general medical and SUD specialty-care settings. This article summarizes the clinical practice guidelines for identifying, diagnosing, and treating SUD in VA and DoD general medical and SUD specialty-care settings, highlights evidence - based pharmacotherapy and psychosocial interventions for managing SUD, and describes barriers to successful treatment of veterans and service members at risk for SUD in VA and DoD health care systems. [Author Abstract]
Back, S. E., Killeen, T., Foa, E. B., Santa Ana, E. J., Gros, D. F., & Brady, K. T. (2012). Use of an Integrated Therapy With Prolonged Exposure to Treat PTSD and Comorbid Alcohol Dependence in an Iraq Veteran. American Journal Of Psychiatry, 169(7), 688-691. doi:10.1176/appi.ajp.2011.11091433
The article presents a case study of a 25-year-old single Caucasian Marine veteran with post-traumatic stress disorder (PTSD) and comorbid alcohol dependence. Patient was treated with a substance use disorder psychotherapy called concurrent treatment of PTSD and substance use disorders using prolonged exposure (COPE). The article discusses PTSD and co-occurring substance use disorders, as well as the use of COPE in treating the condition.
Hoge CW. Interventions for War-Related Posttraumatic Stress Disorder: Meeting Veterans Where They Are.(2011). JAMA.306(5):549-551. doi:10.1001/jama.2011.1096.
Rothbaum, B. O., Gerardi, M., Bradley, B., & Friedman, M. J. (2011). Evidence-based treatments for posttraumatic stress disorder in Operation Enduring Freedom and Operation Iraqi Freedom military personnel. In J. I. Ruzek, P. P. Schnurr, J. J. Vasterling, M. J. Friedman (Eds.), Caring for veterans with deployment-related stress disorders (pp. 215-239). Washington, DC, US: American Psychological Association. doi:10.1037/12323-010
Because PTSD had not been recognized as an official psychiatric disorder by the end of the Vietnam War, there were no routine assessments or recommended treatments for this disorder. In contrast, the U.S. Departments of Defense (DoD) and Veterans Affairs (VA) have instituted systematic and comprehensive screening protocols for PTSD, traumatic brain injury (TBI), depression, and substance abuse to provide Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans evidence-based treatments as soon as possible. There are now several published treatment guidelines for PTSD, including those from the International Society for Traumatic Stress Studies (Foa, Keane, Friedman, & Cohen, 2009), the United Kingdom’s National Institute for Clinical Excellence (2005), VA and DoD (2003), American Psychiatric Association (APA, 2004), Australian Centre for Posttraumatic Mental Health (2007), and a literature review, the Institute of Medicine (2008) report. In the pages that follow, we review the literature on these interventions, including representative studies only if the literature base is large. For a comprehensive review of almost all empirically supported treatments for PTSD, the reader is referred to Foa et al. (2009). (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Karlin, B. E., Ruzek, J. I., Chard, K. M., Eftekhari, A., Monson, C. M., Hembree, E. A., & ... Foa, E. B. (2010). Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. Journal Of Traumatic Stress, 23(6), 663-673. doi:10.1002/jts.20588
Unlike the post-Vietnam era, effective, specialized treatments for posttraumatic stress disorder (PTSD) now exist, although these treatments have not been widely available in clinical settings. The U.S. Department of Veterans Affairs (VA) is nationally disseminating 2 evidence-based psychotherapies for PTSD throughout the VA health care system. The VA has developed national initiatives to train mental health staff in the delivery of Cognitive Processing Therapy (CPT) and Prolonged Exposure therapy (PE) and has implemented a variety of strategies to promote local implementation. In this article, the authors examine VA's national CPT and PE training initiatives and report initial patient, therapist, and system-level program evaluation results. Key issues, lessons learned, and next steps for maximizing impact and sustainability are also addressed. [ABSTRACT FROM AUTHOR]
Roberts, N. P., Kitchiner, N. J., Kenardy, J., & Bisson, J. I. (2009). Systematic review and meta-analysis of multiple-session early interventions following traumatic events. The American Journal Of Psychiatry, 166(3), 293-301. doi:10.1176/appi.ajp.2008.08040590
Objective: The authors sought to determine the efficacy of multiple-session psychological interventions to prevent and treat traumatic stress symptoms beginning within 3 months of a traumatic event. Method: Nine computerized databases were searched, and manual searches were conducted of reference lists of selected articles as well as two journals. In addition, key researchers in the field were contacted to determine whether they were aware of other relevant studies. The reviewers identified randomized controlled trials of multiple-session psychological treatments aimed at preventing or reducing traumatic stress symptoms in individuals within 3 months of exposure to a traumatic event. Details of the studies were independently extracted by two reviewers, and outcome data were entered into the Review Manager software package. Quality assessment was also conducted by two researchers independently. Results: Twenty-five studies examining a range of interventions were identified. For treatment of individuals exposed to a trauma irrespective of their symptoms, there was no significant difference between any intervention and usual care. For treatment of traumatic stress symptoms irrespective of diagnosis, trauma-focused cognitive-behavioral therapy (CBT) was more effective than waiting list or supportive counseling conditions. The difference was greatest for treatment of acute stress disorder and acute posttraumatic stress disorder. Conclusions: Trauma-focused CBT within 3 months of a traumatic event appears to be effective for individuals with traumatic stress symptoms, especially those who meet the threshold for a clinical diagnosis. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Litz, B. T. (2008), Early intervention for trauma: Where are we and where do we need to go? A commentary. Journal of Traumatic Stress, 21: 503–506. doi: 10.1002/jts.20373
In this commentary, the author underscores the importance of early intervention for trauma and describes the challenges that lie ahead for researchers, decision makers, and care providers. The author also provides a review of where things stand, briefly reviews psychological first aid strategies, and underscores where we need to go from here. Although the field has advanced considerably in the last decade or so, and there are compelling trials underway, there is much work that needs to be done, especially in terms of effectiveness and the task of integrating early intervention into various work cultures, such as the military.
PTSD Research Quarterly, National Center for PTSD
Monson, C.M., Schnurr, P.P., Resick, P,A., Friedman, M.J., Young-Xu, Y.; Stevens, S.P. (2006). Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74, 898-907. doi: 10.1037/0022-006X.74.5.898
Sixty veterans (54 men, 6 women) with chronic military-related posttraumatic stress disorder (PTSD) participated in a wait-list controlled trial of cognitive processing therapy (CPT). The overall dropout rate was 16.6% (20% from CPT, 13% from waiting list). Random regression analyses of the intention-to-treat sample revealed significant improvements in PTSD and comorbid symptoms in the CPT condition compared with the wait-list condition. Forty percent of the intention-to-treat sample receiving CPT did not meet criteria for a PTSD diagnosis, and 50% had a reliable change in their PTSD symptoms at posttreatment assessment. There was no relationship between PTSD disability status and outcomes. This trial provides some of the most encouraging results of PTSD treatment for veterans with chronic PTSD and supports increased use of cognitive- behavioral treatments in this population. (PsycINFO Database Record (c) 2013 APA, all rights reserved)
Department of Veterans Affairs & Department of Defense
Department of Veterans Affairs & Department of Defense
Department of Veterans Affairs & Department of Defense
Department of Veterans Affairs & Department of Defense
Taylor, S., Thordarson, D.S., Maxfield, L., Fedoroff, I.C., Lovell, K., & Ogrodniczuk, J.S. (2003). Comparative efficacy, speed, and adverse effects of three PTSD treatments: Exposure therapy, EMDR, and relaxation training. Journal of Consulting and Clinical Psychology, 71, 330-338.
The authors examined the efficacy, speed, and incidence of symptom worsening for 3 treatments of posttraumatic stress disorder (PTSD): prolonged exposure, relaxation training, or eye movement desensitization and reprocessing (EMDR; N=60). Treatments did not differ in attrition, in the incidence of symptom worsening, or in their effects on numbing and hyperarousal symptoms. Compared with EMDR and relaxation training, exposure therapy (a) produced significantly larger reductions in avoidance and reexperiencing symptoms, (b) tended to be faster at reducing avoidance, and (c) tended to yield a greater proportion of participants who no longer met criteria for PTSD after treatment. EMDR and relaxation did not differ from one another in speed or efficacy. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Richard J. McNally, Richard A. Bryant, and Anke Ehlers
In the wake of the terrorist attacks at the World Trade Center, more than 9,000 counselors went to New York City to offer aid to rescue workers, families, and direct victims of the violence of September 11, 2001. These mental health professionals assumed that many New Yorkers were at high risk for developing posttraumatic stress disorder (PTSD), and they hoped that their interventions would mitigate psychological distress and prevent the emergence of this syndrome. Typically developing in response to horrific, life-threatening events, such as combat, rape, and earthquakes, PTSD is characterized by reexperiencing symptoms (e.g., intrusive recollections of the trauma, nightmares), emotional numbing and avoidance of reminders of the trauma, and hyperarousal (e.g., exaggerated startle, difficulty sleeping). People vary widely in their vulnerability for developing PTSD in the wake of trauma. For example, higher cognitive ability and strong social support buffer people against PTSD, whereas a family or personal history of emotional disorder heightens risk, as does negative appraisal of one's stress reactions (e.g., as a sign of personal weakness) and dissociation during the trauma (e.g., feeling unreal or experiencing time slowing down). However, the vast majority of trauma survivors recover from initial posttrauma reactions without professional help. Accordingly, the efficacy of interventions designed to mitigate acute distress and prevent long-term psychopathology, such as PTSD, needs to be evaluated against the effects of natural recovery. The need for controlled evaluations of early interventions has only recently been widely acknowledged.
Psychological debriefing—the most widely used method—has undergone increasing empirical scrutiny, and the results have been disappointing. Although the majority of debriefed survivors describe the experience as helpful, there is no convincing evidence that debriefing reduces the incidence of PTSD, and some controlled studies suggest that it may impede natural recovery from trauma. Most studies show that individuals who receive debriefing fare no better than those who do not receive debriefing. Methodological limitations have complicated interpretation of the data, and an intense controversy has developed regarding how best to help people in the immediate wake of trauma.
Recent published recommendations suggest that individuals providing crisis intervention in the immediate aftermath of the event should carefully assess trauma survivors' needs and offer support as necessary, without forcing survivors to disclose their personal thoughts and feelings about the event. Providing information about the trauma and its consequences is also important. However, research evaluating the efficacy of such “psychological first aid” is needed.
Some researchers have developed early interventions to treat individuals who are already showing marked stress symptoms, and have tested methods of identifying those at risk for chronic PTSD. The single most important indicator of subsequent risk for chronic PTSD appears to be the severity or number of posttrauma symptoms from about 1 to 2 weeks after the event onward (provided that the event is over and that there is no ongoing threat).
Cognitive-behavioral treatments differ from crisis intervention (e.g., debriefing) in that they are delivered weeks or months after the trauma, and therefore constitute a form of psychotherapy, not immediate emotional first aid. Several controlled trials suggest that certain cognitive-behavioral therapy methods may reduce the incidence of PTSD among people exposed to traumatic events. These methods are more effective than either supportive counseling or no intervention.
In this monograph, we review risk factors for PTSD, research on psychological debriefing, recent recommendations for crisis intervention and the identification of individuals at risk of chronic PTSD, and research on early interventions based on cognitive-behavioral therapy. We close by placing the controversy regarding early aid for trauma survivors in its social, political, and economic context.