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Authored by Michelle Fernando, PhD, and Eileen Stran-Joy, PhD
Fidelity to evidence-based treatment was never meant to mean rigidity.
Clinicians and researchers worked for decades to develop trauma-focused EBPs (TFTs)including Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), Written Exposure Therapy (WET), Eye Movement Desensitization and Reprocessing therapy (EMDR), Narrative Exposure Therapy (NET), and trauma-focused Cognitive Behavioral Therapy. These protocols acknowledge that evidence-based practice requires us to integrate research and clinical judgment to individualize care and adapt treatment to real-life contexts. However, the “how” of individualizing care can vary widely between clinicians.
In this article, we sought to survey clinicians from a PTSD specialty clinic on their opinions about common (and sometimes controversial) TFT choice-points. Four clinicians voted on whether or not they use certain individualization strategies and explained their answers via a survey. These choice-points were then compared/contrasted to current research.
Real-life Choice: Do you provide “preparatory” appointments before EBPs? (Votes: 3 yes, 1 maybe, 0 no).
Clinical Impression: Clinicians reported they collaboratively determined the usefulness of preparatory sessions with their patients. They noted sometimes using preparatory sessions to stabilize safety concerns, improve motivation, or build emotional regulation skills, as well as address treatment interfering behaviors early to strengthen rapport and reduce dropout.
Research Impression: Adding preparatory individual or group sessions had no to small effect on symptoms compared to beginning an EBP immediately—and in one study were associated with poorer outcomes. Although limited quantitative data doesn’t support differential outcomes for complex-PTSD, a qualitative review shows patients experience preparatory sessions positively, reporting increased self-efficacy and motivation. Effects on dropout remain unclear.
Real-Life Choice: Do you change treatment based on culture, family background, or preferred learning methods? (Votes: 2 yes, 2 maybe, 0 no).
Clinical Impression: Clinicians acknowledged that EBPs were developed within Western cultural contexts that are not shared by all patients. Suggested individualizing treatment using patient language, incorporating metaphors or spiritual beliefs, and considering the relative safety of exposures based on identity. Such adaptation can improve fidelity to core EBP components.
Research Impression: Growing research supports culturally adapted interventions to improve outcomes. Evidence-supported adaptations include incorporating cultural values in conceptualization, adjusting therapist self-disclosure, using culturally rooted relaxation strategies, and changing analogies, vignettes, and language based on literacy and cultural norms.
Real-Life Choice: Do you change the frequency of appointments to less than or more than weekly? (Votes: 0 yes, 2 maybe, 3 no).
Clinical Impression: Clinicians shared they will offer more frequent sessions when indicated, for example, to help a patient get momentum and overcome avoidance, to provide additional support, or finish treatment in a shorter timeframe. They described avoiding less-than-weekly sessions and may not start a TFT if a patient cannot commit to weekly, but noted that mid-protocol decreases are sometimes unavoidable given patient barriers.
Research Impression: Massed or intensive models of PTSD treatment are effective and may improve retention and treatment completion compared to weekly. Less is known about less-than-weekly sessions, as TFT treatment manuals and corresponding randomized controlled trials are traditionally formatted for weekly sessions. However, outside of EBPs, one study found no association with PTSD symptom reduction, while another found higher session density predicted better clinician-reported outcomes. Other research suggests that dose (i.e., 8 or more sessions for CPT or PE) determines outcome.
Real-Life Choice: Do you provide a supportive therapy instead of doing a TFT? (Votes: 0 yes, 2 maybe, 2 no).
Clinical impression: The overall impression was to prioritize TFT, with some isolated cases benefitting from present-focused or supportive care. One clinician reported doing present-focused skills building for suicide prevention or severe emotion dysregulation. Others reported using supportive therapy for emergent crises during TFT or for ongoing stressors after completing a TFT.
Research impression: Manualized TFTs (e.g., CPT, PE, TF-CBT, etc.) are the most effective choice for treating PTSD, such that these are considered “first-line” treatments in clinical practice guidelines (APA, VA/DoD). Present-centered therapy, a trauma-informed supportive therapy that was originally designed as a therapeutic control for research, is gaining recognition as a second-line approach.
Summary: Adaptation requires an individualized, context-sensitive approach.
None of our adaptation choices had a unanimous “yes” or “no” response, further emphasizing the nuance and complexity of clinical decision making. Alongside treating PTSD, clinicians must juggle patients’ competing presenting concerns, willingness for trauma processing, ability to tolerate intense emotions, and unique contextual factors. Monitoring treatment response, such as regularly tracking PCL-5 scores, may help clinicians determine if their adaptations are working individually. In addition, clinician-informed research is needed to guide TFT adaptations and strengthen clinical decision-making.
Disclosure: This material is supported in part by the Department of Veterans Affairs. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
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