In the past I facilitated a case conference for PTSD treatment, where clinical psychology and social work interns and staff shared cases for consultation. A question came up regarding patients who present with only a short window of time available for treatment, such as 4 to 8 weeks, due to a PCS, separation/retirement, deployment, or other reasons, and are unable to complete a full PE or CPT protocol in weekly sessions. How should a provider best treat a patient with PTSD who has a short timeframe?
The options discussed included:
a) implement a massed version of a protocol
b) start a protocol and then transfer knowing the patient may be unable to locate a trained provider to complete treatment
c) provide targeted aspects of the protocol (essentially symptom management), or
d) provide supportive sessions to build rapport and encourage the patient to re-establish care elsewhere in the future
The residents were split on the issue, with some endorsing a massed protocol (option a) and others endorsing identifying specific techniques from a protocol on which to focus (option c). Surprisingly, several residents also recommended supportive therapy alone (option d).
Of course, being a provider who strongly supports EBPs and (full disclosure) favors PE, I had an initial reaction to the discussion. However, I wanted to get a broader picture of the treatment options in this scenario, since in the real world the answer is so often “it depends.”
I started by polling the interns’ supervisors and other psychology faculty of the clinical psychology internship training program. The responses I received included:
“I focus on…education about [PTSD], building motivation for future engagement in empirically based treatment (CPT or PE), education about how avoidance perpetuates symptoms, education about SUDS [subjective units of distress] /diaphragmatic breathing, contrasting values with current behaviors, and education/identification about "core beliefs" that may have developed in reaction to the trauma, and how these are driving behavior.”
“I'd want to get started with the EBP with the expectation that it'd help get…momentum going and increase the odds that they'd know what they need post-transfer. I fear that going with supportive care would make it more likely that that's all they'd know, expect, prefer, and therefore be what they get next.”
“[If I had 6 or more sessions] I would proceed with the protocol. Otherwise, introducing the fundamentals of the EBPs (e.g., PTSD education, rationale for treatment, exposure vs. avoidance, cognitive distortions, and so on) seems reasonable to start making progress.”
“Given that there can be some increase in symptoms early on in the exposure interventions, I would be reluctant to initiate a full EBP protocol unless I could be assured that we could get through a reasonable portion of the treatment.”
“The issue for me is, what is our obligation once we diagnose a serious health problem? …if the patient truly has PTSD they would greatly benefit from definitive care (treatments that have a chance of working). For me, the course of action would be to either have the PCS cancelled or… assure that the patient could receive definitive care [post-transfer].”
That is, the faculty consensus was to recommend getting as far into treatment as possible (similar to option A if 6+ sessions could be scheduled), with recommendations otherwise split between options B and C. Next, I surveyed our Subject Matter Experts (SMEs) here at CDP for their input which included:
“I would favor option A, if it is at all feasible….it fits well with the original protocol, and we also have heard of cases where it has been used successfully down range in compressed formats.”
“[There is now preliminary data] showing good success with a massed protocol, so this would be the best option, followed by option B, though I would try….to see if I could find a provider for follow-up. The patient is better off with some symptom relief of half a protocol than no symptom relief…”
“I agree with…compressed treatment. Comparing it to physical health issues, if a Service member was identified as having Type 1 diabetes, would the [Primary Care Manager, or PCM] say "Well, the standard of care is insulin therapy but since you (or I) are PCSing, we'll let your next PCM take care of it and we'll just do some glucose monitoring?” … would you ever NOT start CBT for depression or insomnia under the same circumstances? Why is PTSD treatment so different?”
Additionally, a fourth SME agreed with massed treatment as well, for a total of 100% of SMEs surveyed going with option A.
Personally, I would also recommend option A. In the case of PE, the treatment as originally described consists of “one or two weekly sessions” (Peterson, Foa, & Riggs, 2011), meaning PE could be delivered in as quickly as five weeks and not deviate from the protocol. For patients with a shorter timeframe, case study data in military populations now exists demonstrating the effectiveness of PE in as little as a two weeks (see for example Blount et al, 2014), and research with massed treatment in military populations is ongoing (see for example the STRONG STAR website).
Interestingly, a recent study in the UK of patients with PTSD found that those who received an intensive course of a cognitive trauma-focused therapy (that was not PE or CPT) over 7-10 days had similar rates of patient reported remission as long as 40 weeks after treatment compared to ‘standard’ weekly treatment (56.7% remission rate for intensive treatment, 58.1% for standard treatment in weekly sessions over 3 months, 30% remission rate for a manualized supportive therapy treatment; Ehlers et al, 2014). Both intensive and standard cognitive therapy had greater effect sizes than supportive therapy or a wait list control group (d = 1.95, 1.95, 1.07, and .26, respectively). While this study did not address options B and C above, the results suggest to me that not only is a compressed treatment schedule effective, it is the approach more likely to be effective in cases of a brief treatment window as opposed to supportive sessions.
Since we know it is possible to deliver EBPs such as PE and CPT in shorter timeframes than 10-12+ weeks, I propose adjusting the original question to: Why would a provider not implement a PE or CPE protocol for the patient with PTSD who has a short window for treatment?
While ultimately this is a question for each individual therapist to decide, I encourage you to consider whether the decision is based more on true patient availability/interest, or on provider variables, such as ease of sticking with the usual, feeling overwhelmed with your current caseload, or assuming the patient would not want or tolerate massed treatment.
Also, consider how your response as a therapist will shape a patient’s future perspective on treatment-seeking or the effectiveness of treatment. From a patient perspective, to borrow a colleague’s medical analogy from above, would any of us return to a physician who said “You need this medication to treat your diagnosis, but we just don’t have enough time together to see how it will go, so let me tell you about the medication and you can just get someone to prescribe it later.” By the way-I have had a physician tell me that, and as you can imagine I did not return! From my perspective, even with time limitations, we as providers of EBPs have the opportunity to provide the kind of care that will encourage our patients to return until they have been fully treated.
One thing is for sure: this question sparked quite a discussion among all of those I asked. I welcome your comments as well below; let us know what you think!
Diana C. Dolan is a clinical psychologist serving as an evidence-based psychotherapy trainer with the Center for Deployment Psychology. She wrote this article from her experiences while a Deployment Behavioral Health Psychologist for the Wilford Hall Ambulatory Surgical Center’s clinical psychology internship at Lackland AFB, TX, where she provided PTSD treatment-related supervision.
Blount, Tabatha H., Jeffrey A. Cigrang, Edna B. Foa, Haley L. Ford, and Alan L. Peterson. “Intensive Outpatient Prolonged Exposure for Combat-Related PTSD: A Case Study.” Cognitive and Behavioral Practice. 21 (2014): 89-96.
Ehlers, Anke, Ann Hackmann, Nick Grey, Jennifer Wild, Sheena Liness, Idit Albert, Alicia Deale, Richard Stott and David M. Clark. “A Randomized Controlled Trial of 7-Day Intensive and Standard Weekly Cognitive Therapy for PTSD and Emotion-Focused Supportive Therapy.” American Journal of Psychiatry. 171 (2014): 294-304.
Peterson, Alan L., Edna B. Foa and David S. Riggs. “ Prolonged exposure therapy for combat-related PTSD.” Treating PTSD in military personnel: A clinical handbook. Ed. Brent A. Moore and W. Penk. New York, NY: Guilford, 2011. 42–58.