Interventions for posttraumatic stress disorder: a review of the evidence base

Abstract

Given high rates of trauma exposure in South Africa, mental health practitioners often need to deliver interventions to trauma survivors. While there have been few local trauma intervention studies, there is an extensive international evidence base that provides a rich resource on which to draw. This article reviews evidence-based treatments for posttraumatic stress disorder and complex posttraumatic stress disorder. The current weight of evidence supports the use of trauma-focused cognitive behavioural therapy approaches in the treatment of posttraumatic stress disorder and the use of multimodal, phase-based interventions to treat complex posttraumatic stress disorder. There is also a long-standing, though less extensive, evidence base for psychodynamic therapy in the treatment of these conditions, as well as a number of emerging treatment approaches that require further study. While there are some limitations to transferring these approaches to the South African context, the current evidence base provides valuable guidelines for local practitioners seeking to develop their competencies in treating posttraumatic stress disorder and more complex trauma-based presentations.

Keywords

Complex PTSD evidence interventions PTSD review treatment

In South Africa, 75% of the general population of adults has experienced a potentially traumatic event (Williams et al., 2007). Consequently, mental health practitioners across all settings in South Africa will almost inevitably work with trauma survivors at some point. Practitioners therefore need to have the competencies to deliver effective interventions to clients presenting with trauma-related difficulties. Fortunately, the field of traumatic stress has yielded an enormous amount of research on the treatment of trauma-related disorders, and particularly posttraumatic stress disorder (PTSD). While this surfeit of knowledge is a wonderful resource for practitioners, it can also be somewhat bewildering to navigate. In order to render this vast literature more digestible to practitioners, this article provides a review of the treatment literature for PTSD, with an emphasis on interventions that have demonstrated robust evidence for their effectiveness. First, the review will be contextualized within ongoing debates and developments in the field of traumatic stress. Thereafter, the evidence base for PTSD interventions will be reviewed. Finally, some commentary on the implications of this evidence base for the South African context will be provided.

The emphasis on psychotherapeutic treatment of traumatic stress in this article should in no way be seen as detracting from a commitment to broader-scale interventions that are designed to tackle the kinds of social and political forces that produce trauma exposure in the first instance. Peacebuilding and group and community interventions to address structural forms of violence, gender-based violence, crime, youth delinquency, and xenophobia, among other issues, are vitally important in attempting to decrease the numbers of people exposed to victimization and trauma of various kinds. However, until such approaches begin to substantially reduce the incidence of violence and trauma, there remains an urgent need to treat those who have been affected by exposure to trauma, using the most effective interventions available.

Contextualizing interventions for PTSD and trauma-related disturbances

It should be emphasized that PTSD represents a very specific form of debilitating trauma impact that affects a minority of those exposed to traumatic events. Trauma exposure can produce a spectrum of responses ranging from mild, temporary impairment that remits spontaneously with time, to intractable effects that manifest in personality disturbances and incapacitating symptomatic presentations. There is recognition that complicated forms of traumatic stress beyond PTSD exist and require further theorization and research. Notable among these are complex traumatic stress (Ford & Courtois, 2009) or complex-PTSD (C-PTSD; Herman, 1992). In addition, acute stress disorder (ASD), developmental trauma disorder (DTD), poly-traumatization, occupation-related traumatic stress, collective and historical traumatization, identity-related trauma, and continuous traumatic stress (CTS) have all been offered as alternative formulations for particular types of trauma exposure and the manner in which they may present (for example, see Eagle & Kaminer, 2015). It is not possible to do justice to the intervention requirements for this range of conditions, and, as the ensuing elaboration of approaches will indicate, the bulk of documented material on intervention pertains to the diagnosed condition of PTSD. This article presents an overview of current findings related to psychotherapeutic treatment of PTSD specifically, with a short section on treatment approaches for C-PTSD, for which there is an expanding body of research. However, it is important to note that complicated forms of traumatic stress may require alterations to existing treatment protocols or complementary or completely different kinds of intervention. For example, collective or historical trauma, affecting large groups of people by virtue of shared identity characteristics, may well require broad-scale interventions such as truth commissions, memorialization, social justice, and reparation (Hamber, 2009), while working with people in contexts of CTS requires a strong focus on daily threat discrimination and safety planning rather only on trauma exposure work (Eagle & Kaminer, 2013; Murray, Cohen, & Mannarino, 2013). It should also be acknowledged that the timing of therapeutic interventions requires consideration, ‘psychological first aid’, and support being appropriate in the immediate aftermath of exposure, whereas more extended trauma-focused therapy is indicated once PTSD has been diagnosed and the impact of the traumatic event has become more enduring.

In reviewing evidence-based treatments (EBTs) for PTSD, it is also important to bear in mind that the definition of what constitutes clinical ‘evidence’ for treatment effectiveness is not entirely straightforward. Following the convention for pharmacotherapy treatments and public health interventions, within clinical psychology, there is increasing emphasis on randomized controlled trials (RCTs) as the gold standard for evaluating interventions, and evidence-based practices (EBPs) or EBTs are now largely synonymous with RCT-based evidence (Kazdin, 2014). In the past 15 years, there has been a plethora of RCTs for PTSD, and there are now internationally recognized Cochrane reports amassing and summarizing RCT studies of the treatment of PTSD (Bisson & Andrew, 2007) and acute traumatic stress conditions (Rose, Bisson, Churchill, & Wessely, 2002), as well as a meta-analysis of treatments for chronic PTSD (Bisson et al., 2007). Such evaluations are being used to produce best practice guidelines in a number of countries, and practitioners are expected to be aware of and led by such guidelines. Forbes et al. (2010) provide a useful summary comparison of formally adopted guidelines for the treatment of ASD and PTSD, including those of the American Psychiatric Association (APA), the Veterans Administration (VA), the UK-based National Institute for Health and Clinical Excellence (NICE), the International Society for Traumatic Stress Studies (ISTSS), the Australian Centre for Posttraumatic Mental Health, the Institute of Medicine, and the American Academy of Child and Adolescent Psychiatry (AACAP), all of which have been produced relatively recently. With few exceptions, the guidelines tend to promote trauma-focused cognitive behaviour therapies that have been evaluated using RCTs. However, there is recognition of the need for some flexibility in adoption of approaches, and some guidelines include attention to psychodynamic approaches, group interventions, play therapy for children, and expressive therapies, among others.

RCT research does, however, have its limitations. These include the use of somewhat controlled and contrived ‘laboratory’ conditions and carefully selected samples that do not mimic real-world clinical or community-based contexts, as well as a failure to qualitatively assess participants’ experiences of the interventions and impacts (Kazdin, 2014). In both general psychotherapy research (Dattilio, Edwards, & Fishman, 2010) and PTSD research in particular (Edwards, 2005), the need to supplement RCTs with systematic case study evidence has been advocated.

Although it is laudable that there is increasing attention to providing evidence for the credibility of interventions and the ethical commitment to client welfare that this move suggests, critics note that this approach is led to some extent by the cost-efficiency considerations of managed health care providers. In addition, given the resources required to produce gold standard efficacy studies such as RCTs, involving large numbers of participants and practitioners, it is not surprising that the bulk of such studies have been produced in high-income settings such as the United States, Europe, Australia, and the United Kingdom. This means that the research base is biased towards what might be considered ‘western’ populations and forms of practice, and there have been questions about the transportability and cross-cultural applicability of existing findings (Summerfield, 2008). Since there are no guidelines for traumatic stress treatment that are specifically tailored for the South African context, local practitioners tend to be guided by international findings. However, it is important to note that a high number of South African citizens are likely to consult traditional or faith healers in the aftermath of traumatic events, particularly because exposure to ‘misfortune’ may well be ascribed to supernatural causes such as failure of protection by ancestors or ‘bewitchment’ (Eagle, 2005). This means that many cases of ASD or PTSD may be treated by people other than psychologists and psychiatrists and that integrative forms of intervention may need to be considered (Eagle, 1998). It is generally accepted that further research into trauma interventions in non-Westernized contexts is imperative, even if studies cannot always achieve the highest levels of rigor in terms of efficacy research.

With this broader context in mind, it is nevertheless useful to outline what current writing on PTSD treatment has revealed with increasing refinement of research and practice. Cognitive behavioural and psychodynamic interventions for PTSD will be reviewed in some detail, as much of the existing treatment literature has emerged from these modalities. Emerging interventions from other modalities, that await further evaluation, will then be briefly identified.

Cognitive behavioural therapy for PTSD

Based on extensive findings from RCT studies, cognitive behavioural therapy (CBT) that has a trauma focus demonstrates the strongest evidence for the treatment of PTSD. At least five different, evidence-based, trauma-focused CBT (TF-CBT) interventions are available to clinicians who are treating clients with PTSD (Cusack et al., 2016; Schnyder et al., 2015) and, increasingly, training in at least one of these approaches is considered to be a professional and ethical requirement for those who regularly provide psychotherapy to survivors of trauma. These treatment models include prolonged exposure (PE; Foa & Rothbaum, 1998), cognitive processing therapy (CPT; Resick & Schnicke, 1992), cognitive therapy for PTSD (CT-PTSD; Ehlers & Clark, 2000), eye movement desensitization and reprocessing (EMDR; Shapiro, 1995), and narrative exposure therapy (NET; Schauer, Neuner, & Elbert, 2005).

While encompassing generic CBT principles and techniques (including psychoeducation, exposure, and cognitive restructuring), these treatments for PTSD are distinguished by the fact that their content is very deliberately trauma focused. The five interventions listed above are typically 8–12 sessions in length and contain a number of common elements, including psychoeducation about the impact of trauma and symptoms of PTSD, some degree of exposure to traumatic memories (and, in some cases, also in-vivo exposure to trauma-related stimuli), and cognitive reprocessing of the belief and meaning elements associated with these memories. However, there are fairly substantial differences in emphasis and in techniques of treatment delivery across these approaches, as will be discussed below. An ongoing debate in the research literature is whether these models represent substantively different mechanisms of change or whether all CBT treatments are underpinned by essentially the same active ingredients and are ultimately interchangeable. As we will indicate, some comparative and dismantling studies have attempted to address this question.

Summary of evidence-based CBT interventions

PE has the strongest evidence of all the CBT treatments for PTSD, having accumulated the largest number of RCT studies demonstrating its effectiveness (Cahill, Rothbaum, Resick, & Follette, 2010). Originally developed by Foa and Rothbaum (1998) to treat survivors of rape with PTSD, PE has been effectively applied to survivors of other traumatic events as well (Goodson, Lefkowitz, Helstrom, & Gawrysiak, 2013). It has two primary elements. The first element entails the therapist guiding the client to engage in repeated, step-by-step retelling of their most distressing traumatic memory. These retellings are followed by identification of the client’s beliefs and associated feelings that are activated by the trauma memory. Maladaptive beliefs (such as beliefs about self-blame that may be linked to strong feelings of guilt or shame) are then challenged by the therapist through cognitive techniques. It is hypothesized that repeated exposure to the feared memory within the safe environment of the therapy, together with the process of disconfirming negative cognitions, will extinguish the fear and anxiety associated with the trauma memory and reduce intrusive and hyperarousal symptoms (Schnyder et al., 2015). The second primary element of PE is gradual in-vivo exposure to situations in the client’s life that are objectively safe but have become associated with the traumatic event and are therefore feared and behaviourally avoided. Both imaginal exposure (with reprocessing of maladaptive beliefs) and in-vivo exposure appear to contribute unique treatment gains, and used together are more effective in reducing symptoms than either method alone (Cahill et al., 2010).

In a 2010 meta-analysis of RCTs for PE, PE demonstrated a large effect for both PTSD and secondary outcomes such as depression, as well as moderate to large effect sizes at follow-up. However, while PE was consistently superior to wait list and supportive therapy control groups, there was no significant difference between PE and other ‘active’ therapies, including CPT, CT-PTSD, and EMDR (Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010). Furthermore, there are some concerns about the tolerability of PE, given the repeated exposure of clients to distressing trauma-related material. Some reviews have pointed to high drop-out rates across PE studies (Kehle-Forbes, Meis, Spoont, & Polusny, 2016; Schottenbauer, Glass, Arnkoff, Tendick, & Gray, 2008), although since PTSD is characterized by avoidance of trauma-related material, this is rather unsurprising. Other studies have found that therapists are reluctant to engage in PE, despite its strong evidence base, due to concerns about retraumatizing their clients (Becker, Zayfert, & Anderson, 2004; Cahill, Foa, Hembree, Marshall, & Nacash, 2006). The weight of evidence from RCTs suggests that PE is substantially more likely to make clients better than to make them worse (Jayawickcreme et al., 2013); however, as will be discussed in more detail later, clients with C-PTSD linked to childhood abuse are likely to benefit from a phase of skills training in emotion regulation and interpersonal relating before engaging in PE.

Like PE, CPT was developed to treat rape-related PTSD in particular, but has since been used with combat veterans (Monson et al., 2006). In its original form, it entailed the client writing a narrative of the trauma and then reading this to the therapist, followed by identification and cognitive reprocessing of maladaptive trauma-related beliefs related to ‘stuck points’ in the trauma narrative (Resick & Schnicke, 1992). However, a later dismantling study by the treatment developers suggested that detailed accounts of the trauma slowed down the client’s progress in therapy while adding nothing to the final treatment outcome (Resick et al., 2008). A cognitive-only version of the model (called CPT-C) was therefore developed, which excludes the written trauma account and focuses mainly on identifying the most difficult trauma-related beliefs – those that create significant emotional conflict for the survivor (Schnyder et al., 2015). Reprocessing these beliefs is then the main aim of the intervention. Arguably, some element of exposure is still maintained by talking about trauma-related beliefs, even without the detailed, step-by-step retelling of a trauma memory (Schnyder et al., 2015). Both CPT and CPT-C have consistent support from several well-designed RCTs (Galovski, Schuster Wachen, Chard, Monson, & Resick, 2015).

CT-PTSD aims to reduce negative trauma-related appraisals, to reduce intrusive symptoms through elaborating trauma memories and discriminating trauma triggers from realistic danger cues, to change cognitive and behavioural strategies that maintain a sense of threat, and to help survivors to reclaim activities and relationships that have been lost due to trauma symptoms (Ehlers & Wild, 2015; Schnyder et al., 2015). There is substantial support for this approach from several RCTs with adults, and these generally have had low drop-out rates, suggesting tolerability despite the exposure element (Ehlers & Wild, 2015). Furthermore, there is some case study evidence to support its application in the South African context (Edwards, 2009).

Often characterized as an integrative therapy, EMDR encompasses the core exposure and reprocessing elements of the above CBT treatments, but combines these with bilateral stimulation which is theorized to enhance the processing of trauma-related memories, affects, and cognitions (Spates, Koch, Cusack, Pagoto, & Waller, 2010). The bilateral stimulation, often achieved through having the client track back-and-forth eye movements or by the therapist tapping the client on alternating sides of the body, accompanies the client’s recounting of a traumatic memory and its associated sensations. It is also carried out in later stages of treatment to assist with the installation of positive cognitions and images. While there was initially a great deal of controversy regarding EMDR, and particularly the role of bilateral stimulation, in the past several years, EMDR has accumulated a very solid evidence phase to support its effectiveness in survivors of both civilian and combat trauma (Spates et al., 2010).

Among the TF-CBT interventions, NET is the new kid on the block. NET was developed in recognition of the possibility that survivors of war, torture, conflict, or organized violence may present with specific treatment needs due to multiple exposures to trauma and a scarcity of trained mental health professionals (Schauer et al., 2005). NET begins with the client using string, a ribbon, or similar material to construct a ‘lifeline’ that represents their life from birth, through to the present day, and some time into the future. The lifeline is then chronologically populated with symbols (such as stones or flowers) to represent both traumatic experiences and significant positive events. Using an adaptation of PE techniques, all traumatic events are then narrated in detail. A written testimony of the client’s experiences is developed and given to the client at the end of therapy. Notably, NET is the only CBT intervention for PTSD that has a substantial evidence base outside of the global North. NET was originally developed to be delivered in refugee camps by lay counsellors, and unlike the CBT interventions reviewed above, it has developed cumulative evidence to show that it can be effectively delivered by non-professionals in low- and middle-income countries (Robjant & Fazel, 2010). Consequently, it is currently recommended as the PTSD treatment of choice in conflict or post-conflict settings where mental health professionals are scarce (Mørkved et al., 2014).

With regard to the treatment of PTSD and other trauma-related difficulties in children and adolescents, TF-CBT (Cohen, Mannarino, & Deblinger, 2006) is recommended as the first-line treatment (Lenz & Hollenbaugh, 2015). TF-CBT is an adaptation of CBT therapies for adult PTSD. It includes psychoeducation, relaxation skills, cognitive coping skills, developing a trauma narrative, identifying and restructuring maladaptive traumatic beliefs, and planning for future safety. While it can be delivered as an individual intervention, it was designed as a conjoint therapy involving both children/adolescents and their caregivers, recognizing the important role of caregiver support in ameliorating trauma-related difficulties in young people. While much of the evidence supporting TF-CBT has emerged from high-income countries, a recent RCT in Zambia found the model to transfer well to an African context and to be effective when delivered by lay counsellors (Murray et al., 2015). Although other interventions for children with PTSD have been developed and evaluated, the evidence base to support them remains limited compared with TF-CBT (Cohen, Mannarino, Deblinger, & Berliner, 2010).

Comparisons between CBT interventions

All these relatively short-term evidence-based CBT approaches can present a somewhat overwhelming array of options to mental health practitioners working with trauma survivors. How do they stand up to each other? Some meta-analyses have found little difference in efficacy across different TF-CBT interventions (Bisson & Andrew, 2007; Cloitre, 2009). A very recent systematic review and meta-analysis of psychological treatments for PTSD graded the current strength of evidence (SOE) for all the above interventions, with regard to the number and rigor of RCTs conducted to date and their findings regarding effectiveness (Cusack et al., 2016). The review suggests that PE currently enjoys the strongest SOE, that CPT and cognitive therapy (CT) have moderate SOE, while EMDR and NET, the most recently developed treatments, currently have low to moderate SOE. The review further indicates that head-to-head evidence is currently insufficient to draw clear conclusions about comparative effectiveness across treatments (Cusack et al., 2016). It seems unlikely that a single treatment will be effective for all clients with PTSD, and clearly the practitioner’s choice of intervention should be tailored to the client’s individual needs and preferences, rather than mechanistically applied. Furthermore, the selection of a treatment approach needs to be weighed up against concerns about tolerability of the different models to clients and therapists, as well as accessibility of these treatment approaches in contexts where there is a scarcity of trained mental health professionals and an absence of affordable opportunities for receiving training in specific models.

Best practice guidelines for the treatment of PTSD frequently emphasize the need for the client to actively engage with traumatic material in order to reprocess it in a more helpful and adaptive manner and recommend that exposure-based interventions are the first-line treatments for PTSD (Cahill et al., 2010). However, it is important to note that there is some evidence to suggest that direct engagement with traumatic material may not be a necessary ingredient for PTSD symptom reduction (Benish, Imel, & Wampold, 2008). For example, stress inoculation training, which provides training in anxiety management skills without focusing specifically on reviewing traumatic memories, has been found to be more effective than supportive counselling, wait-list controls, or routine clinical care in reducing PTSD (Cahill et al., 2010). Furthermore, a recent study comparing PE with interpersonal therapy, a non-CBT intervention that focuses on developing strategies for addressing current interpersonal difficulties, found the latter to be as effective as the former (Markowitz et al., 2015). In line with broader research on ‘common factors’ in psychotherapy (Wampold & Imel, 2015), these findings may suggest that non-specific therapeutic factors (like the therapeutic alliance), rather than a specific technique (like retelling the trauma memory), may be responsible for producing some improvements in PTSD. However, it must be borne in mind that studies supporting these treatments for PTSD are still very limited, that the sustainability of treatment gains for these modalities remains unclear, and that the weight of evidence currently indicates that directly addressing traumatic memories using CBT techniques is more effective than other approaches (Ehlers et al., 2010).

Treating C-PTSD

There has been some debate in the treatment literature about whether the TF-CBT therapies described above are suitable for the treatment of more complex forms of trauma linked to experiences of relational abuse. For example, C-PTSD (Herman, 1992) has been proposed as a diagnostic formulation that accounts for the psychological impact of prolonged child abuse or adult relational abuse. Like borderline personality disorder (BPD), which is strongly but not universally associated with a history of childhood abuse (MacIntosh, Godbout, & Dubash, 2015), the most prominent symptoms of C-PTSD are difficulties with affect regulation, sense of identity, and interpersonal relationships. It has been argued that many CBT treatment studies for PTSD tend to exclude patients with symptoms of complex trauma or BPD (Bradley, Greene, Russ, Dutra, & Westen, 2014; Spinazzola, Blaustein, & van der Kolk, 2005). Since such patients tend to make up a significant portion of clinic populations (Wurr & Partridge, 1996), there is a need for treatment studies that specifically target this population.

Compared with the broader evidence base for treating PTSD, a relatively limited number of studies have evaluated the effectiveness of TF-CBT for (1) patients with histories of childhood victimization presenting with PTSD or (2) patients presenting with symptoms of C-PTSD. A recent meta-analysis suggests that both PE and CPT significantly reduce symptoms of PTSD related to childhood abuse as well as symptoms of C-PTSD, but that substantial symptoms remain post-treatment, particularly for C-PTSD (Dorrepaal et al., 2014). With regard to EMDR, current evidence does not support its use for addressing symptoms of complex trauma, at least not without substantially extending and adapting the treatment (Korn, 2009). CT-PTSD and NET have not been evaluated for use with complex traumatic stress presentations.

Given the considerable diagnostic overlap between C-PTSD and BPD, it makes sense to turn to the BPD treatment literature when seeking guidance for treating patients with complex trauma presentations. Dialectical behaviour therapy (DBT; Linehan, 1993), which encompasses emotion regulation and interpersonal skills, has the strongest evidence base for treating BPD (Panos, Jackson, Hasan, & Panos, 2014). However, it does not include a focus on specific traumatic events and does not target PTSD symptoms, so may be insufficient for treating the substantial number of patients who present with comorbid BPD and PTSD (Zanarini et al., 1998).

Consequently, the more recent treatment literature for C-PTSD (whether of child or adult onset) advocates a multimodal, phase-based approach, starting with the development of emotion regulation and interpersonal skills using DBT-based techniques and then moving on to more traditional TF-CBT treatments such as PE or CPT to address PTSD symptoms (Cloitre et al., 2011; Courtois, Ford, & Cloitre, 2009). At least eight treatment studies have targeted C-PTSD symptoms in patients with childhood abuse histories, all using a multimodal and phase-based approach (see Cloitre et al., 2011). For example, Cloitre, Cohen, and Koenen (2006) have developed STAIR-NST (Skills Training in Affective and Interpersonal Regulation/Narrative Story-Telling), a flexible approach that begins with emotion regulation and interpersonal skills development and then proceeds with PE. The effectiveness of this model has been supported by two RCTs (see Cloitre et al., 2011). However, as the sampling procedures, measurement of symptoms, and treatment protocols have varied substantially across C-PTSD treatment studies, few firm conclusions can yet be drawn about the best choice of treatment. Of note, for the South African context, which has a substantial population of refugees and asylum seekers, the value of multimodal approaches (encompassing safety and stabilization, TF-CBT, and dealing with loss) has also been recognized in the literature on the treatment of populations displaced by war or conflict, who often present with complex symptom profiles linked to past trauma exposure and ongoing insecurity and threat (Nickerson, Bryant, Silove, & Steel, 2011).

Psychodynamic treatment for PTSD

Much of the earliest formulation of traumatic stress and its impact arose within the psychoanalytic tradition, with Freud engaging in considerable depth with the theorization of war-related and other forms of catastrophic stressors, including recommendations for therapeutic treatment (Wilson, Friedman, & Lindy, 2012). In many respects, aspects of Freud’s conceptualization of traumatic stress as involving a breach of ‘ego boundaries’ and compromising anxiety control and regulation mechanisms have prefigured subsequent theorization in the area and resonate with the idea that treatment goals should include facilitating a return to functional anxiety management, among other aspects. From its origins, psychodynamic practitioners have engaged in trauma-focused work as an integral part of their practice, with Garland’s (1998) edited book, Understanding Trauma: A Psychoanalytical Approach bringing together some of the seminal work in the area by British clinicians. In America, writers such as Horowitz (1997), Lindy (1993), and Krupnick (1980, 2002) contributed significantly to the traumatic stress literature on psychodynamic ways of formulating and treating trauma-related impacts. While early writing on traumatic stress treatment gave some prominence to psychodynamic approaches, more recently references to PDT have diminished markedly with the current focus being very clearly on CBT, as discussed above. This is in large measure due to the increasing weight of emphasis on EBPs and the fact that psychodynamic treatment approaches have been difficult to manualize or standardize and to subject to gold standard effectiveness studies. Within the psychoanalytic community, there appears to be increasing recognition of the need to engage in rigorous, efficacy-oriented research, including comparison-based studies. There is also evidence of review and meta-analytic studies (Fonagy, 1999; Fonagy, Roth, & Higgitt, 2005; Leichsenring, Hiller, Weissberg, & Leibing, 2006; Leichsenring & Leibing, 2007) systematically bringing together research evidence on psychodynamic treatments for a range of psychiatric conditions, including PTSD. It should be noted that in a number of countries around the world, including South Africa, psychodynamic approaches to trauma treatment continue to be favoured (Nacash et al., 2011, cited in Levi, Bar-Haim, Kreiss, & Fruchter, 2015; Schottenbauer, Glass, Arnkoff, & Gray, 2008).

In relation to traumatic stress–related conditions, there is not a great deal of very recent writing on psychodynamic treatment approaches, although the revised version of Effective treatments for PTSD: practice guidelines from the International Society for Traumatic Stress Studies (Foa, Keane, Friedman, & Cohen, 2008) includes chapters on psychodynamic treatment with both adults and children. Krupnick (2002) has detailed the outlines of a brief psychodynamic treatment for single event PTSD that entails supportive and exploratory aspects. It uses a supportive therapeutic relationship to uncover what the specific event and circumstances that follow mean to the individual and the obstacles to normal psychological processing of these events:

The aim of the psychodynamic therapist is both to identify the phase of traumatic response in which the individual seems to be caught and to formulate the aspects of the event itself, the individual who experienced the event, and the pre- and post-event environment that interfere with normal psychological processing and integration of the trauma. (Krupnick, 2002, pp. 920–921)

The model has three phases. The first four sessions are spent building a therapeutic alliance and a sense of safety as well as inviting the person to tell their ‘trauma story’. The second phase (usually sessions 5–8) entails a process of ‘working through’, looking in some depth at self-image and interpersonal relational dynamics that have emerged or been reignited as a consequence of the trauma. This phase involves making links between individual developmental experiences and the manner in which these may have influenced trauma responses as well as examining the manner in which the therapeutic relationship may also reflect aspects of the trauma experience (as evidenced in heightened dependence or displaced aggression, for example). The final phase (sessions 9–12) addresses the inevitable sense of loss that accompanies trauma and allows for realistic assessment of the likely ongoing processing of the traumatic experience that will be required going forward. There is only one systematic study of this trauma treatment approach using before and after measures with no control group (Krupnick, 1980) demonstrating reasonable success in treating crime-related trauma. However, as is common for much of the psychodynamic work with traumatized patients, the model is supported largely by practitioner accounts and case study–based presentations (e.g., Chertoff, 1998; Krupnick, 2002; Moss, 2009).

Lindy (1993) also developed a psychodynamically informed trauma treatment model involving three phases. The model is very similar to that outlined by Krupnick (2002), with the first phase entailing the building of a strong working alliance and the final phase also entailing aspects of mourning in incorporating the trauma experience into the person’s life history. However, in the middle ‘working through’ phase, greater attention is paid to defenses and how these have shaped the processing of the traumatic event. The overall aim of the approach is to process the trauma in considerable depth in order for it to be integrated rather than repressed. Lindy, Green, Grace, MacLeod, and Spitz (1988) were able to demonstrate considerable benefits in an uncontrolled study of the intervention with Vietnam veterans, including gains beyond symptom reduction, such as ‘less estrangement, more investment in adult roles, and constructive activities, and continuity with a sense of self before the war’ (Schottenbauer et al., 2008, p. 16).

In keeping with CBT approaches, it is evident that psychodynamic approaches to trauma treatment are also ‘trauma focused’ in the main rather than being more generally support focused. Psychodynamic therapists also take a more active, directive role in trauma-focused work than is conventional in more general psychodynamic therapy. However, where psychodynamic approaches tend to differ from CBT approaches is in placing greater emphasis on the exploration of less conscious aspects of the trauma experience, rather than on more readily accessible trauma-related beliefs or schemas. Psychodynamic theorists understand both the specific nature of symptom presentation and the more intractable aspects of trauma responses to be strongly connected to the personal history and personality make-up of the individual concerned, including, for example, their characteristic defenses. Thus, while they accept generic models of trauma impact, they believe that understanding unique individual aspects of response is vital to treatment.

What is the existing evidence base for PDT in the treatment of PTSD? In one of the few control-based studies on brief psychodynamic treatment for traumatic stress (based in large measure on Horowitz’s earlier work), involving 112 patients and comparison with trauma desensitization and hypnotherapy, Brom, Kleber, and Defares (1989) were able to demonstrate that in terms of longer term outcomes, psychodynamic psychotherapy appeared more effective in reducing avoidance symptoms in comparison with the other approaches, which were more efficacious in reducing intrusion-related symptoms. In a very recent comparative study of treatment of combat-related PTSD among Israeli veterans by means of CBT and PDT, Levi et al. (2015) found no significant difference in treatment efficacy with both treatments leading to improved functioning and 35% of the CBT treatment group and 45% of the PDT-treated patients showing remission of PTSD post-treatment, dropping to 33% and 36%, respectively, at the 8- to 12-month follow-up. Given that the patients in this case suffered from relatively chronic PTSD, these results were viewed as favourable in relation to therapeutic benefit. Levi et al. conclude that it may be useful for clinics and trauma practitioners to be familiar with and offer both modalities, given that different patients may be more or less comfortable with either approach, making it more or less likely that they will stay in treatment over time. They suggest that initial assessment may be helpful in determining suitability of assignment to treatment type but fail to fully elaborate on what might be predictive of preference. Despite their promotion of short-term trauma-focused PDT, Levi et al. (2015) acknowledge that given the similarity in outcome, pragmatism might favour CBT approaches since these tend to be of shorter duration and are therefore more cost effective. Referring to the work of others in addition to their own study, Levi et al. (2015) conclude their article by arguing, ‘since PTSD can be treatment resistant and persistent, having a range of effective treatment options may be a very relevant factor in providing PTSD care’ (p. 9).

Perhaps, the most useful contemporary summary on psychodynamic approaches to treating PTSD and trauma is the review article by Schottenbauer et al. (2008), bringing together conceptual arguments and research findings from a broad swathe of empirical treatment literature. Schottenbauer et al. (2008) note the need for further, more rigorous research into psychodynamic treatments of traumatic stress, particularly given their continued popularity in many settings. They make several well-substantiated arguments for the benefits of psychodynamic approaches relative to the widely promoted CBT-type interventions. First, they suggest that the exposure-based components of most CBT-based treatments can prove aversive to some individuals, particularly those suffering from severe forms of trauma, such as torture, contributing to high drop-out rates and non-completion of courses of treatment, suggesting that the more supportive and gradually paced nature of PDT may be more palatable for such patients. Second, they argue that given the form that C-PTSD takes, almost inevitably manifesting in problematic interpersonal relational styles and patterns and difficulties with affect regulation, psychodynamic approaches are better suited to work with such populations. In addition, they note that PTSD has very high levels of co-morbidity with other disorders, including personality disorders, and suggest that ‘psychodynamic psychotherapy may prove to be particularly appropriate for addressing reactions to trauma that have become entrenched in personality traits or disorders’ (Schottenbauer et al., 2008, p. 25), noting that research findings suggest limited success for CBT-based interventions for these populations, although, as discussed previously, Cloitre et al.’s (2011) recent work appears to counter this latter observation. Schottenbauer et al. (2008) also provide evidence to suggest that psychodynamic treatments may be cost-effective in that they produce long-term benefits that are sustained over time, aspects of the treatment being internalized and consequently providing the basis for continuing improvements. Overall, Schottenbauer et al. (2008) make a strong case for psychodynamic treatment of traumatic stress conditions, in particular, more complicated presentations, and suggest that they offer the potential for holistic intervention. As they summarize in their abstract,

empirical and clinical evidence suggests that psychodynamic approaches may result in improved self-esteem, increased ability to resolve reactions to trauma through improved reflective functioning, increased reliance on mature defenses with concomitant decreased reliance on immature defenses, the internalization of more secure working models of relationships, and improved social functioning. (Schottenbauer et al., 2008, p. 13)

In terms of the compromised daily functioning that accompanies PTSD and related diagnoses, as well as what might be termed the more existential impacts of trauma exposure, it seems that psychodynamic approaches may be of considerable benefit. However, it appears that even those promoting psychodynamic approaches are compelled to acknowledge that at present, the evidence base for such interventions is not sufficiently strong.

Emerging treatments for PTSD

The field of traumatic stress is expanding all the time and a number of emergent PTSD treatment models warrant acknowledgement. Body-oriented approaches, meditation, and mindfulness-based methods all have a small but growing evidence base (Cloitre, 2009), and there is ongoing neuropsychological research into interventions (Bomyea & Lang, 2012). The practice guidelines for the treatment of PTSD offered by the ISTSS further recognize emerging evidence to support hypnosis (Cardena, Maldonado, van der Hart, & Speigel, 2010) and group therapy approaches (Tracie Shea, McDevitt-Murphy, Ready, & Schnurr, 2010). The latter are often employed to supplement individual treatment, and group membership is usually structured around common forms of traumatization, such as victimization through sexual assault or combat-related trauma. In South Africa group, approaches have been favoured in the treatment of collective and other forms of traumatization as exemplified, for example, in the Khulamani support group for families of victims of apartheid atrocities, playing both advocacy and therapeutic roles.

As noted earlier in this review, there can be no ‘one-size-fits-all’ treatment approach for PTSD, and the continued exploration of different PTSD treatment modalities is therefore of value. However, it is important for practitioners to be aware of the evidence supporting the use of each treatment approach and to be somewhat cautious in adopting a treatment for which the evidence base remains inadequate or is still emerging.

Conclusion

As illustrated in the above review, South African mental health professionals have an array of treatments to select from when working with trauma-related difficulties. At present, CBT interventions have the strongest evidence base for both adult and child PTSD and for C-PTSD. There is also clinical research literature to support the use of psychodynamic therapy and an emergent evidence base for some other approaches. There are, however, a number of limitations in applying the existing evidence base to the South African context. Local PTSD treatment outcome research to date largely constitutes case study evidence (e.g., Padmanabhanunni & Edwards, 2015; Payne & Edwards, 2010) which, while valuable, needs to be supplemented with RCTs that include both outcome evaluations of treatment effectiveness and implementation evaluations that examine the contextual and cultural ‘fit’ of the intervention. Without this, it is difficult to evaluate the transferability or exportability of evidence-based PTSD and C-PTSD treatments that have been developed outside the South African context. Furthermore, mental health needs in resource-constrained contexts like South Africa would be best served by task-shifting approaches that allow interventions to be delivered at community level by non-professionals (Mendenhall et al., 2014), yet few PTSD or C-PTSD interventions (with the exception of NET and TF-CBT) have accumulated evidence to suggest that they can be effectively delivered by lay counsellors or other non-professionals. Finally, EBTs developed in clinic settings and targeted at very specific symptoms are attractive in their apparent simplicity but are sometimes inadequate to address real-world complexities. Trauma exposure in South Africa seldom occurs in isolation from other ongoing life stressors such as economic deprivation, failures in delivery of basic services such as electricity and water, ongoing community or domestic violence, and living with chronic health conditions such as HIV/AIDS or diabetes. Interventions that target PTSD or C-PTSD alone can enhance client resilience but may be insufficient to address overarching distress and improve client functioning. Integrative, multimodal approaches, applied with flexibility and sensitivity to the individual needs, resources, and meaning systems of each client, remain of paramount importance.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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