Cognitive-Behavioral Therapy for PTSD: A Case Formulation Approach

Trauma is a huge source of mental distress, and often lies hidden beneath the initial presenting features of many cases we see in clinical practice. In this book, the authors provide a well informed and researched guide for clinicians who may find the complex clinical picture and traumatic experiences presented by patients with PTSD, as well as the prospect of carrying out exposure with them, rather daunting. The authors offer a thoughtful caveat in the preface that readers “may find some of the vignettes in this book unpleasant and graphic”. Their aim is to provide a realistic clinical context and to prepare therapists for hearing about these details in session. The book achieves its purpose admirably. Cognitive-Behavioral Therapy for PTSD is the fourth book in a series of Guides to Individualized Evidence-Based Treatment edited by Jacqueline B. Persons. This series aims to “provide evidence-based roadmaps for managing real-world cases…with an emphasis on systematic yet flexible case formulation.” The book is well structured and clearly written. Many of the chapters include helpful handouts which the authors encourage clinicians to copy or adapt for their own purposes. The numerous clinical examples and sample dialogues provided throughout demonstrate the authors’ breadth of experience with patients with PTSD. The first chapter provides an overview of the core components of cognitive-behavioral therapy (CBT) for PTSD, and summarizes the research supporting CBT for PTSD. The second chapter provides an overview of the cognitive-behavioral conceptualization of PTSD. The third chapter covers how to use the case formulation approach to select and tailor interventions to suit the individual needs of patients with complex clinical presentations. The authors discuss how to conduct a comprehensive assessment of patients with PTSD, then illustrate how to integrate case specific with generic evidence-based formulations, as well as how to approach treatment when patients present with another disorder as the primary concern, though the clinician suspects that PTSD may underlie the presenting problem. In the rest of the book the authors describe in detail the elements of PTSD treatment. Chapter four covers several issues that may arise when embarking on CBT for PTSD: establishing a trusting relationship; addressing the therapist’s discomfort about increasing patients’ distress; deciding whether a patient is ready to start exposure, and whether to start with exposure or cognitive restructuring; and potential barriers to treatment such as life problems or practical concerns. Chapter five provides detailed information about implementing the main components of psychoeducation in CBT for PTSD. Chapter six covers what patients learn during both in vivo and imaginal exposure, the fundamentals and common pitfalls of carrying out in vivo exposure with patients with PTSD, and strategies for dealing with problems in in vivo exposure. This chapter contains particularly helpful sections on what to do if the patient’s anxiety does not diminish during exposure, and how to tackle flashbacks during in vivo exposure.