The Range of Psychotherapies for PTSD

To the Editor: In the June 2018 issue of the Journal, Murray Stein and Barbara Rothbaum note in their generally clear-sighted and useful overview of the history of posttraumatic stress disorder (PTSD) and its treatment that “trauma-focused treatments had more evidence for their efficacy in the treatment of PTSD than any other intervention” (1, p. 512). This is undeniably the case, but there are psychotherapeutic alternatives to trauma-focused treatment. Inasmuch as Stein and Rothbaum also accurately indicate that current treatments have limited efficacy, a more balanced perspective might have indicated that trauma-focused exposure treatment is not for everyone (patients or therapists)—there is no panacea—and that alternative treatments with growing evidence bases exist. Having the most evidence does not discount other evidence. Focusing on affect and interpersonal issues may provide an alternative to a cognitive-behavioral trauma focus, and there is room for both. The Journal has published studies of nonexposure interpersonal psychotherapy (2), which in one trial showed comparable overall outcome to prolonged exposure therapy and advantages for patients with sexual trauma–related PTSD or major depression, as well as studies of skills training in affect and interpersonal regulation therapy (3). These empirically supported treatments are beginning to appear in treatment guidelines (4).

I join Stein and Rothbaum’s call for further research on psychotherapies and pharmacotherapies for PTSD, and I add that research should cover all, not just some, of the promising bases. Our field has too often suffered from ideological schism (5, 6), yet there is room and need for more than one treatment approach for most psychiatric disorders.