Why New Psychotherapies for PTSD?

Ulrich Schnyder
Zurich, Switzerland

The efficacy of psychotherapeutic and pharmacotherapeutic approaches in the treatment of PTSD can be regarded as empirically demonstrated (Foa et al., 2000; Livanou, 2001; Sherman, 1998). Overall, effect sizes seem to be higher for psychotherapy as compared with medication (van Etten and Taylor, 1998). Psychotherapy for PTSD includes the following approaches:

Cognitive-Behavioral Therapy (CBT) uses a variety of techniques such as exposure, cognitive processing and restructuring, stress inoculation training, assertiveness training, and relaxation techniques. CBT usually is offered as a time-limited psychotherapy, averaging approximately eight to 12 sessions, with meetings once or twice weekly. Many well-controlled trials with a mixed variety of trauma survivors have demonstrated that CBT is effective in treating PTSD (Foa et al., 2000; Foa and Rothbaum, 1998; Foa et al., 1991; Marks et al., 1998; Tarrier et al., 1999). More specifically, exposure therapy currently is seen as the treatment modality with the strongest evidence for efficacy (Foa et al., 2000).

Eye Movement Desensitization and Reprocessing (EMDR) is a technique in which the patient, under the guidance of a therapist, carries out horizontal eye movements while he or she recalls the traumatic scenes. Although the clinical efficacy of this technique has been well documented, EMDR still remains controversial. A meta-analysis revealed that EMDR is similarly effective in comparison to other exposure techniques but that eye movements in particular have no incremental therapeutic effect (Davidson and Parker, 2001).

Psychodynamic Therapy seeks to reengage normal mechanisms by addressing what is unconscious and, in tolerable doses, making it conscious. This is accomplished by exploring the psychological meaning of a traumatic event. It may include sifting and sorting through wishes, fantasies, fears and defenses stirred up by the event (Foa et al., 2000). Transference and countertransference, and the therapist-patient relationship, are crucial factors in this approach. Although varying in length, psychodynamic therapy is usually of longer duration than CBT. Unfortunately, only few empirical investigations with randomized designs and validated outcome measures have been reported (Brom et al., 1989), so currently there is no sufficient evidence indicating that psychodynamic therapy is effective in reducing PTSD symptomatology.

Brief Eclectic Psychotherapy (BEP) has been proposed by Gersons and collaborators as a fully manualized, multimodal treatment approach that combines educational, cognitive-behavioral and psychodynamic elements. It comprises five essential elements: 1) psychoeducation; 2) guided imagery (exposure); 3) writing assignments and mementos; 4) the domain of meaning and integration; and 5) a farewell ritual. BEP proved to be effective in reducing PTSD symptoms in police officers suffering from chronic PTSD, as compared with a wait-list control group (Gersons et al., 2000). In addition, the improvement demonstrated for PTSD symptoms progressed further in all outcome measures, including return to work, three months after termination of treatment. However, these promising results need to be replicated independently, applying BEP in more general trauma populations.

There is no doubt that psychotherapy is an effective component in the treatment of patients suffering from PTSD. Why then should we keep searching for new psychotherapeutic approaches? Here are some reasons:

The incidence of traumatic events is increasing worldwide, confronting us with cycles of violence that are becoming more destructive. Further research into the devastating consequences of traumatic events and, even more urgent, into the development of more effective therapeutic interventions aimed at ameliorating trauma-related psychiatric disorders is of utmost importance.

References

Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Foa EB, Kessler RC, McFarlane AC, Shalev AY (2000). Consensus statement on posttraumatic stress disorder from the International Consensus Group on Depression and Anxiety. Journal of Clinical Psychiatry 5, 60-66.

Brom D, Kleber RJ, Defares PB (1989). Brief psychotherapy for posttraumatic stress disorders. Journal of Consulting and Clinical Psychology 57, 607-612.

Davidson PR, Parker KCH (2001). Eye movement desensitization and reprocessing (EMDR): a meta-analysis. Journal of Consulting and Clinical Psychology 69, 302-316.

Foa EB, Keane TM, Friedman MJ (2000). Effective treatments for PTSD: practice guidelines from the International Society for Traumatic Stress Studies. Guilford Press, Guilford Press.

Foa EB, Rothbaum BO (1998). Treating the Trauma of Rape: Cognitive-Behavioral Therapy for PTSD. Guilford Press, Guilford Press.

Foa EB, Rothbaum BO, Riggs DS, Murdock TB (1991). Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive-behavioral procedures and counseling. Journal of Consulting and Clinical Psychology 59, 715-723.

Gersons BPR, Carlier IVE, Lamberts RD, van der Kolk BA (2000). Randomized clinical trial of brief eclectic psychotherapy for police officers with posttraumatic stress disorder. Journal of Traumatic Stress 13, 333-348.

Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB (1995). Posttraumatic stress disorder in the national comorbidity study. Archives of General Psychiatry 52, 1048-1060.

Livanou M (2001). Psychological treatments for post-traumatic stress disorder: an overview. International Review of Psychiatry 13, 181-188.

Marks I, Lovell K, Noshirvani H, Livanou M, Thrasher S (1998). Treatment of posttraumatic stress disorder by exposure and/or cognitive restructuring: a controlled study. Archives of General Psychiatry 55, 317-325.

Resick PA, Nishith P, Weaver TL, Astin MC, Feuer CA (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology 70, 867-879.

Rothbaum BO, Foa EB (1993). Subtypes of Posttraumatic Stress Disorder and Duration of Symptoms. In: Davidson JR, Foa EB (eds) Posttraumatic Stress Disorder: DSM-IV and Beyond. American Psychiatric Press, Washington, DC, pp 23-35.

Sherman JJ (1998). Effects of psychotherapeutic treatments for PTSD: a meta-analysis of controlled clinical trials. Journal of Traumatic Stress 11, 413-435.

Tarrier N, Pilgrim H, Sommerfield C, Faragher B, Reynolds M, Graham E, Barrowclough C (1999). A randomized trial of cognitive therapy and imaginal exposure in the treatment of chronic posttraumatic stress disorder. Journal of Consulting and Clinical Psychology 67, 13-18.

van Etten ML, Taylor S (1998). Comparative efficacy of treatments for post-traumatic stress disorder: a meta-analysis. Clinical Psychology and Psychotherapy 5, 126-144.

Ulrich Schnyder, MD, is professor of psychiatry and head of the department of psychiatry at University Hospital in Zurich, Switzerland