7

Treatment

This chapter provides critical reviews of the various approaches to treatment for chronic posttraumatic stress disorder (PTSD), that is, PTSD lasting more than 3 months, although many of the treatments may be used with patients who suffer from acute PTSD (lasting more than 1 month and less than 3 months) and even those who have symptoms within 2 weeks after a traumatic event. The chapter begins with a description of the many psychosocial therapies whose efficacy is supported by an established evidence base—randomized controlled trials (RCTs). Among the psychosocial treatments discussed are exposure therapy, cognitive therapy, and group therapy. That is followed by a discussion of treatments that have been studied in open trials and for which RCTs have not been conducted. The efficacy of pharmacotherapy for PTSD is then considered, including the use of antidepressants—serotonin reuptake inhibitors (SRIs) and others— and the use of multiple drugs for PTSD and comorbid conditions. The efficacy of combinations of cognitive behavioral therapy and pharmacotherapy for PTSD is also discussed. The committee then looks at emerging treatments that are being used or being considered for use in the management of PTSD. These include manualized treatments (that is, those that have a manual of instructions) such as couple psychotherapy in which one or both persons have PTSD, and complementary and alternative medicine (CAM) treatments, most of which do not have a structured manual, such as yoga, acupuncture, and animal-assisted therapy. A synopsis of the many PTSD treatment guidelines is then given, including the Department of Veterans Affairs (VA)/Department of Defense (DoD) guideline for the management



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7 Treatment T his chapter provides critical reviews of the various approaches to treatment for chronic posttraumatic stress disorder (PTSD), that is, PTSD lasting more than 3 months, although many of the treatments may be used with patients who suffer from acute PTSD (lasting more than 1 month and less than 3 months) and even those who have symptoms within 2 weeks after a traumatic event. The chapter begins with a descrip- tion of the many psychosocial therapies whose efficacy is supported by an established evidence base—randomized controlled trials (RCTs). Among the psychosocial treatments discussed are exposure therapy, cognitive therapy, and group therapy. That is followed by a discussion of treatments that have been studied in open trials and for which RCTs have not been conducted. The efficacy of pharmacotherapy for PTSD is then considered, including the use of antidepressants—serotonin reuptake inhibitors (SRIs) and others— and the use of multiple drugs for PTSD and comorbid conditions. The effi- cacy of combinations of cognitive behavioral therapy and pharmacotherapy for PTSD is also discussed. The committee then looks at emerging treat- ments that are being used or being considered for use in the management of PTSD. These include manualized treatments (that is, those that have a manual of instructions) such as couple psychotherapy in which one or both persons have PTSD, and complementary and alternative medicine (CAM) treatments, most of which do not have a structured manual, such as yoga, acupuncture, and animal-assisted therapy. A synopsis of the many PTSD treatment guidelines is then given, including the Department of Veterans Affairs (VA)/Department of Defense (DoD) guideline for the management 231

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232 PTSD IN MILITARY AND VETERAN POPULATIONS of posttraumatic stress that might assist the health care provider in selecting a treatment plan for a patient with PTSD. There are numerous interventions for chronic PTSD, and not all of them have a robust database to support their efficacy for ameliorating PTSD symptoms. Not having RCTs supporting a particular treatment does not necessarily mean that it is not effective. The committee believes it is prudent to offer treatment supported by robust evidence before offering treatments that are not so supported. It should be noted that many of the treatments discussed in this chapter, even those with a robust body of evi- dence, may not have been tested specifically on military personnel who had PTSD, but in the absence of a well-reasoned argument against it, it is safe to hypothesize that treatments that were effective in well-controlled studies of a variety of civilian populations that had PTSD will also be effective in military personnel. Not all people who have PTSD respond satisfactorily to initial treat- ment, and many remain treatment-resistant to varied degrees. Some guide- lines offer recommendations on levels of care or stages of treatment in the event that the first evidence-based approaches fail to produce a satisfactory response. There is no widely accepted definition of what constitutes satis- factory response. Some studies use at least a 50% reduction in PTSD symp- toms to indicate a satisfactory response; another indicator of a satisfactory response is a score of 15 on the Posttraumatic Stress Diagnostic Inventory to indicate subclinical PTSD severity and a score of 10 to indicate remission (Foa et al., 1993). On the Clinician-Assisted PTSD Scale (CAPS), subclinical PTSD is indicated by a score of 50, and remission by a score of 20 or less (Tucker et al., 2001). The percentage of responders varies among studies, types of traumas, definitions of response, magnitudes of intent to treat, and completer analyses. Depending on the specific cognitive behavioral treat- ment and the study sample, the percentage of responders can be as high as 90% and as low as 50% (Kar, 2011), and treatment outcomes are stable over time (e.g., Foa et al., 2005). The evidence base for the best second- and third-line line treatment ap- proaches for PTSD falls substantially, and more reliance is placed on expert opinion rather than empirical information. Examples of those treatments are antidepressants or use of an antipsychotic drug with a selective sero- tonin reuptake inhibitor (SSRI) in cases of partial SSRI response, watchful waiting for the first 4 weeks after trauma for those who have mild symp- toms, but brief cognitive behavioral therapy (CBT) even within the first month in more severe cases.

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233 TREATMENT PSYCHOSOCIAL TREATMENTS FOR CHRONIC PTSD This section describes the psychosocial treatments whose efficacy has been examined in RCTs. A review of treatments whose efficacy has been examined in open trials follows, and finally, treatments that have been suggested but whose efficacy has not been examined are briefly described. Treatments Supported in Randomized Controlled Trials The vast majority of treatments that have been examined via RCT are in the general group of psychosocial therapies called cognitive behavioral therapy. They include exposure therapies, stress inoculation training or anxiety-management programs, and cognitive therapies. Many treatment programs combine components of each of those general treatment groups, and CBT has become an overarching concept that includes variants of exposure therapy, stress inculcation training, cognitive therapies, and their combinations. Exposure Therapies Exposure therapies are designed to reduce PTSD symptoms and related problems (such as depression, anger, and guilt) by helping patients to con- front their trauma-related situations, memories, and feelings. Exposure in- terventions include imaginal exposure, which consists of repeated revisiting of the traumatic memory, and in vivo exposure, which involves confronting feared situations that are objectively safe. Treatment programs that include both kinds of exposure, such as prolonged exposure (PE), tend to produce better outcomes than programs that consist of only one of the components (e.g., Bryant et al., 2008). Many RCTs have consistently shown that several exposure therapy protocols for PTSD are effective, and they have been recommended as a first-line treatment for PTSD by several treatment guidelines, such as the National Institute for Health and Clinical Excellence (NICE) and Australian National Health and Medical Research Council guidelines. The most commonly used exposure protocol is PE (Foa et al., 2007). PE is based on emotional-processing theory (Foa and Kozak, 1986), which posits that anxiety disorders, including PTSD, reflect specific pathologic fears of places, situations, or objects that are safe but are perceived as dan- gerous, and therefore, are avoided (Foa and Cahill, 2001). PE is designed to modify PTSD sufferers’ typical erroneous perceptions that “The world is an utterly dangerous place” and “I am completely incompetent and unable to cope with stress.” The central components of PE are in vivo exposure and imaginal exposure. In vivo exposure consists of having the patient

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234 PTSD IN MILITARY AND VETERAN POPULATIONS gradually and systematically approach situations, places, and people that he or she has been avoiding. Through repeated exposure to those stimuli, the dysfunctional, unrealistic expectations of harm are disconfirmed, and the patient experiences a reduction in the associated fear response. Imaginal exposure involves revisiting the memory in imagination and recounting the traumatic event in a way that promotes emotional engagement with the trauma memory and then processing the revisiting experience. Processing provides an opportunity for patients to examine their beliefs related to the trauma memory and to gain a new perspective on the trauma. Like in vivo exposure, repeated, prolonged imaginal exposure provides information that disconfirms dysfunctional erroneous cognitions and reduces the distress associated with confronting the memory. Psychoeducation and controlled- breathing exercises play a secondary role in PE. Psychoeducation comprises a discussion about what maintains PTSD and the reactions that commonly follow a trauma; controlled-breathing training is designed to lower a per- son’s baseline level of anxiety, which might have become heightened in part by rapid and shallow breathing. Treatment commonly consists of 8 to 12 sessions of 60–90 minutes each. Many RCTs—the largest number of such trials of any psychosocial treatment for PTSD—indicate that PE effectively reduces PTSD symptoms in a variety of populations (such as female rape survivors, male and fe- male veterans, and refugees; see Cahill et al., 2009, for a full review). PE is effective for both chronic PTSD (e.g., Foa et al., 1999a, 2005; Resick et al., 2002) and acute stress disorder (Bryant et al., 1999; Foa et al., 1995, 2006). Patients treated with PE generally maintain their gains at follow-ups of a year or more (e.g., Foa et al., 2005; Resick et al., 2002). In addition, PE consistently has been associated with rapid change and maintenance of large effect sizes over time (e.g., Foa et al., 2005). A recently published long-term follow-up study of civilians treated with cognitive processing therapy and PE indicated about 80% of participants were treated to the point of remission at the posttreatment point and remained in remission for 5–10 years after the end of treatment (Resick et al., 2011). PE produces significantly greater pretreatment to posttreatment reduc- tions in PTSD symptoms than supportive counseling (Bryant et al., 2003; Schnurr et al., 2007), relaxation training (Marks et al., 1998; Taylor et al., 2003; Vaughan et al., 1994), and treatment-as-usual, including pharmaco- therapy (Asukai et al., 2010), nonexposure-based individual psychotherapy (Boudewyns and Hyer, 1990), and combinations of psychopharmacology, counseling, and group therapy (e.g., Nacasch et al., 2010). A similar protocol that includes both imaginal and in vivo exposure was developed by Marks et al. (1998). Imaginal exposure is conducted in the first half of the treatment and in vivo exposure in the second half. Only two RCTs used this protocol: Marks et al. (1998) and Taylor et al. (2003).

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235 TREATMENT Because of the similarity between the Foa et al. and Marks et al. protocols, the committee does not distinguish between them in this section. Other Forms of Exposure Therapy Variations of exposure therapy have been shown to be efficacious in RCTs. For example, Resick et al. (2008) compared cognitive processing therapy (CPT), which includes cognitive therapy and written exposure, with written exposure of the traumatic memory only and without the cognitive component of CPT without writing (see “Cognitive Therapies” section). Written exposure consisted of two preparatory sessions followed by five 2-hour sessions in which the patient was asked to write for about 60 minutes alone about his or her experienced trauma and then to read the narrative to the therapist, who provided unstructured supportive feedback. The written-exposure group did nearly as well as the group that had CPT with and without writing; at the 6-month follow-up, there was no signifi- cant difference between the groups. Van Emmerik et al. (2008) also found that structured writing therapy was as efficacious as cognitive therapy in treatment for PTSD. Exposure in the context of a broader narration of the patient’s life also has empirical support. For example, narrative exposure therapy, a brief manualized treatment, has been shown to be efficacious for treating PTSD in war-ravaged refugee populations (Neuner et al., 2008). A variation of this treatment is testimony therapy, which is a brief nonmanualized indi- vidual intervention designed for survivors of war; however, the only RCT found no difference between this treatment and wait list (WL) both soon after and 11 months after treatment (Igreja et al., 2006). Blanchard et al. (2003) developed CBT–MVA (motor vehicle accident), a short-term manualized exposure therapy protocol that targets victims of motor vehicle incidents who have PTSD. CBT–MVA includes in vivo ex- posure, progressive muscle relaxation, cognitive restructuring, one session of couple therapy (if the patient has a spouse) and one session focusing on anger or existential issues stemming from the incident. In an RCT, patients who received CBT–MVA reported greater reductions in PTSD symptoms than patients who received supportive psychotherapy, who in turn reported greater reductions in PTSD than those on WL. Gains made in the two treat- ment groups were maintained at 3 months. Imagery rescripting (Smucker et al., 1995) is another exposure therapy protocol that has been examined in RCTs both as an addendum to PE and as a stand-alone therapy for victims of childhood sexual abuse. The patient first engages in an imaginal exposure, immediately followed by a rescript- ing, in which the patient is encouraged to revisit the trauma while develop- ing mastery imagery by imagining himself or herself as an adult entering

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236 PTSD IN MILITARY AND VETERAN POPULATIONS the room during the trauma and rescuing and protecting the vulnerable child (Cukor et al., 2009). An RCT compared imaginal exposure coupled with imagery rescripting with imagery rescripting alone and found that both groups experienced improvement in PTSD symptoms with those on WL. There were no differences between the two treatment groups (Arntz et al., 2007). McLean and Foa (2011) reviewed the evidence base for exposure ther- apy. Several meta-analyses of exposure therapy (e.g., Bradley et al., 2005) have found that it is far more effective than WL or supportive therapy and as effective as SSRIs in the short-term with lower dropout rates, but data on long-term effects are sparse (Van Etten and Taylor, 1998). Other meta-analyses have shown that exposure therapy is more effective than “non–trauma-focused” treatments or WL in reducing PTSD symptoms, but the differences in outcomes among the different exposure therapies was not significant (Bisson and Andrew, 2007; Seidler and Wagner, 2006). A recent meta-analysis of 13 PE studies found a large effect size for PE compared with WL or psychological placebo immediately after treatment that was maintained at follow-up (Powers et al., 2010). Studies have also shown that PE leads to significantly greater pretreatment to posttreatment reductions in PTSD symptoms than supportive counseling (Bryant et al., 2003; Schnurr et al., 2007), relaxation (Marks et al., 1998; Taylor et al., 2003; Vaughan et al., 1994), and treatment-as-usual (Asukai et al., 2010; Boudewyns and Hyer, 1990; Cooper and Clum, 1989; Nacasch et al., 2010). Furthermore, comparative treatment studies have found PE to be of at least comparable efficacy with other forms of CBTs, such as stress inoculation training (SIT), CPT, cognitive therapy (CT), and eye movement and desensitization repro- cessing (EMDR) (Bryant et al., 2003, 2008; Foa et al., 1991, 1999a, 2005; Marks et al., 1998; Paunovic and Ost, 2001; Power et al., 2002; Resick et al., 2002, 2008; Rothbaum et al., 2005; Schnurr et al., 2001; Tarrier et al., 1999; van Emmerik et al., 2008; see Powers et al., 2010, for meta-analytic review of these findings). Finally, adding SIT or CT to PE has little benefit (Foa et al., 1999a, 2005). In a comprehensive review of RCTs for exposure therapy for PTSD, an Institute of Medicine (IOM) committee looked at 23 studies, 8 of which met the committee’s quality criteria for inclusion in its assessment. These studies demonstrated a statistically significant improvement in patients receiving exposure therapy based on a primary PTSD scale or loss of a diagnosis of PTSD. The committee found that “the evidence is sufficient to conclude the efficacy of exposure therapies in the treatment of PTSD” (IOM, 2008). In conclusion, there is strong evidence of the efficacy and effectiveness of variants of exposure therapy, in particular PE, in different trauma popu- lations on the basis of studies conducted in independent centers around the world. Treatment benefits have been maintained at 5–10 years follow-up

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237 TREATMENT (Resick et al., 2011). Exposure therapy has also been successfully dis- seminated among community therapists in individual clinics in the United States and other countries and in large mental health systems, such as that of the VA. Cognitive Therapies CT (Beck et al., 2005) is a treatment protocol in which the therapist helps the patient to identify and modify the negative thoughts and beliefs that are considered to underlie pathologic emotions and behaviors. In PTSD treatment, the target is thoughts and beliefs related to a traumatic experience (for example, survival guilt, self-blame for causing the trauma, feelings of personal inadequacy, or worries about the future) with the goal of modifying them to reduce PTSD symptoms and improve mood and functioning. In several RCTs, CT alone has been shown to be an effective intervention for patients who have PTSD with significant reductions in PTSD symptoms (Cottraux et al., 2008; Marks et al., 1998; Resick et al., 2008; Tarrier et al., 1999). CPT (Resick et al., 2002) is a manualized treatment that combines as- pects of CT and PE. It consists of four components: education about specific PTSD symptoms and how the treatment can be beneficial, increasing the pa- tient’s awareness of his or her thoughts and feelings, learning skills to help patients question or challenge maladaptive thoughts, and understanding that experiencing a trauma can change a person’s beliefs about the world and relationships. The aim of CPT is to help patients find a better balance between the beliefs they had before and after their trauma. The treatment program consists of 12 1-hour sessions delivered over 6 weeks. The original protocol included an exposure component in the form of repeated writing of the traumatic memory and reading of it to the therapist. Resick et al. (2008) disentangled the effects of the cognitive component of CPT and the component of writing and reading of the traumatic memory by comparing three groups: full CPT protocol, CT without writing, and writing alone. Although patients in all three groups showed substantial improvement, CT alone showed greater reduction in PTSD symptoms than writing alone. However, at the end of treatment there was no superiority to CPT with and without writing, and writing and reading alone were almost as efficacious as the other two protocols. The writing and reading protocol requires much less therapist training than CPT and seems to be less expensive. Resick is examining the efficacy of group and individual CPT in military personnel. Elhers and Clark (2000) have developed a CT protocol for PTSD that is based on their cognitive model of PTSD. The protocol focuses on modi- fying negative thoughts about the trauma and its consequences, reducing

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238 PTSD IN MILITARY AND VETERAN POPULATIONS re-experiencing by elaboration of the trauma memories and identification of triggers, and encouraging patients to stop dysfunctional behaviors and cognitive strategies. CT also uses in vivo and imaginal exposure. This treat- ment has been evaluated in two RCTs (Ehlers et al., 2003, 2005), both of which found it to be efficacious. Kubany et al. (2003) developed a specific CT protocol for female vic- tims of spousal violence. Cognitive trauma therapy for battered women who have PTSD is a manualized short-term treatment that includes a num- ber of treatment elements adapted from other CBTs for PTSD—including psychoeducation about PTSD, stress management (including relaxation training), and exposure—and other techniques, including reducing irratio- nal guilt-related beliefs and negative self-talk by the women about guilt and shame. Two RCTs that compared cognitive trauma therapy for battered women to WL found that patients who received the treatment experienced large reductions in PTSD symptoms, depression, and guilt, and increases in self-esteem (Kubany et al., 2003, 2004). In conclusion, variants of CT have received support for their efficacy through well-controlled studies. However, the number of studies of each treatment program is small compared with exposure therapy. Eye Movement Desensitization and Reprocessing EMDR (Shapiro, 1989a,b) is a manualized treatment to assist patients in accessing and processing traumatic memories while bringing them to an adaptive resolution (Shapiro, 2001). The patient is asked to access a dis- turbing image associated with the traumatic event, solicit the experience of body sensations associated with the image, identify a negative self-referring belief, and identify a preferred positive belief to replace the negative belief. The patient is then asked to hold the disturbing image, sensations, and the negative belief or thought in mind while tracking the clinician’s moving finger back and forth in front of his or her visual field for about 20 seconds. This process is repeated until the patient has no negative associations with the targeted image. Results of four RCTs suggest that EMDR is an efficacious treatment for PTSD. Lee et al. (2002) and Power et al. (2002) found that its results were equivalent to those of CBT. Taylor et al. (2003) found PE to be more ef- fective than EMDR and relaxation training; moreover, PE, but not EMDR, was significantly more efficacious than relaxation (the control condition). Rothbaum et al. (2005) found that in a 6-month follow-up a significantly larger fraction of patients who received PE were responders than of those who received EMDR. Several studies (e.g., Davidson and Parker, 2001; Spates et al., 2009) have examined the relative contribution of the eye-movement component

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239 TREATMENT and found no effects of its efficacy. Consequently, some PTSD treatment experts posit that the efficacy of EMDR is due to the exposure component that it shares with other existing, successful treatments, such as PE. An IOM committee that critically assessed four RCTs for EMDR concluded that the evidence was inadequate to determine its efficacy for the treatment of PTSD (IOM, 2008). Imagery Rehearsal Therapy Imagery rehearsal therapy (IRT) targets the nightmares that are a com- mon symptom of PTSD by changing the content of a patient’s nightmares to promote mastery over the content threat, thereby altering the meaning and importance of and orientation to the nightmares. In a small RCT, Krakow et al. (2001) compared IRT and WL and found that among treatment completers, participants who received IRT had a larger reduction in self- reported PTSD severity at the 3-month follow-up, the impact of their night- mares was reduced, and their sleep quality improved. However, a recent large RCT comparing IRT with a group nightmare-management treatment in Vietnam veterans with PTSD found that neither treatment produced significant or sustainable improvement in overall PTSD symptom severity, nightmare frequency, or sleep quality (Cook et al., 2010). Thus, although IRT has empirical support as being an effective treatment for nightmares, its efficacy as a treatment for PTSD is questionable. Psychodynamic Psychotherapy Brom et al. (1989) conducted an RCT to compare the efficacy of Horowitz’s (1976) brief psychodynamic therapy, which focuses on solving intrapsychic conflicts that result from a traumatic experience, with hyp- notherapy, trauma desensitization, and a WL control group. Not all study participants met the criteria for PTSD. Re-experiencing and avoidance symptoms improved significantly in all treatment groups but not in the WL group; no differences were found among the three treatments. Brief Eclectic Psychotherapy Gersons et al. (2000) developed manualized brief eclectic psychother- apy, which includes imaginal exposure combined with relaxation, writing assignments, use of mementos of the traumatic experience, exploration of meaning, a farewell ritual, and psychoeducation. Significant reductions in PTSD symptoms and anxiety symptoms were detected compared with the result of WL in an RCT of 42 police officers after the 16 sessions and at 3-month follow-up. It is unclear which of the several treatment compo-

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240 PTSD IN MILITARY AND VETERAN POPULATIONS nents are responsible for the improved outcomes. Lindauer et al. (2005) conducted an RCT with 24 patients and found that brief eclectic psycho- therapy resulted in a reduction in PTSD and symptoms of general anxiety compared with WL. Hypnosis Hypnosis is defined as a heightened state of relaxation during which a health professional or researcher guides a person with suggestions for expe- riencing changes in sensations, perceptions, thoughts, or behaviors (Everly and Lating, 2004). Hypnotic techniques have been used as an adjunctive therapy focusing on nightmares and insomnia in PTSD (Kirsch, 1999; Spiegel and Spiegel, 1987). Brom et al. (1989) found hypnosis to decrease intrusive symptoms more than WL, but not all research participants met the criteria for PTSD. Abramowitz et al. (2008) compared hypnotherapy with the use of zolpidem in an RCT of veterans who had combat PTSD and insomnia. All patients were already taking an SSRI. Hypnotherapy improved PTSD symptoms, sleep quality, and ability to concentrate more than zolpidem did. Relaxation Three RCTs have examined the efficacy of relaxation used in control groups in the study of imaginal exposure, EMDR, PE, or CT (Marks et al., 1998; Taylor et al., 2003; Vaughan et al., 1994). The results of the studies suggest that relaxation has at best a moderate effect on PTSD symptoms, but it is not as effective as exposure or cognitive therapy. Stress Inoculation Training SIT (Meichenbaum, 1974) was developed as an anxiety-management treatment and has been modified to treat rape victims (Kilpatrick et al., 1982). SIT includes relaxation training, breathing retraining, positive think- ing and self-talk, assertiveness training, and thought stopping (Foa et al. 1999b). Some SIT protocols also include cognitive restructuring and expo- sure therapy. Two studies have compared the efficacy of SIT in the treat- ment of female sexual assault victims who had PTSD with the efficacy of PE, supportive counseling, and WL (Foa et al., 1991) and with the efficacy of SIT plus PE (Foa et al., 1999a). Both studies found SIT to be more ef- fective than WL in reducing PTSD and related symptoms and to be of comparable efficacy to PE on some measures. Chemtob et al. (1997) found that SIT was more effective than anger management and treatment-as-usual in reducing anger and re-experiencing of symptoms.

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241 TREATMENT Interpersonal Therapy Interpersonal therapy (IPT) is a manualized time-limited structured psychotherapy. Targeted IPT interventions seek to improve distressing in- terpersonal problems (role conflict, role transition, and loss) and thus to lead to greater social support with consequent benefits regarding mood and anxiety. Because PTSD is often accompanied by problems with intimate familial relationships, it has been hypothesized that treatment that focuses on interpersonal concerns would lead to amelioration of PTSD symptoms. A single RCT compared individual IPT with WL in a small sample of Sudanese refugees living in Cairo, Egypt (Meffert et al., 2011). The authors used conservative intent-to-treat analyses and found that IPT predicted a significant decrease in symptoms of PTSD, state anger, and depression. Skills Training in Affect and Interpersonal Regulation Cloitre et al. (2002) developed a two-phase treatment consisting of eight sessions of skills training in affect and interpersonal regulation (STAIR) fol- lowed by eight sessions of imaginal exposure. The two-phase combined treatment was more effective than WL in increasing emotional regulation and reducing PTSD. Imaginal exposure but not STAIR reduced PTSD symp- toms; moreover, imaginal exposure increased emotional regulation as much as did STAIR despite being delivered at the second stage of treatment. In a follow-up study, Cloitre et al. (2010) compared the combination of STAIR and imaginal exposure with counseling and imaginal exposure. There was a tendency for STAIR and imaginal exposure to produce more recovery from PTSD, but the difference was not significant. Behavior Activation In small RCTs (Jakupcak et al., 2010; Wagner et al., 2007) and open trials (Nixon and Nearmy, 2011), behavioral activation has been shown to be an effective CBT intervention for PTSD, although more well-controlled studies are needed to determine efficacy. The primary goal of this model is to assist people in accessing their emotions and experiences while focusing on living a fulfilling life as opposed to avoiding and escaping pain (Hayes et al., 2006). The treatment is implemented in both groups and individuals. Five specific themes shape the manualized program: escape does not work effectively and leads to “creative helplessness,” efforts to control pain cre- ate struggles, people are separate from their thoughts, moving beyond the struggle for control is central, and moving toward a commitment to action that is consistent with world views and values. The model has been evalu-

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