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EFFECTIVE TREATMENTS FOR PTSD
Effective Treatments for
PTSD
Practice Guidelines from
the International Society
for Traumatic Stress Studies
THIRD EDITION
edited by
David Forbes
Jonathan I. Bisson
Candice M. Monson
Lucy Berliner
THE GUILFORD PRESS
New York London
Copyright © 2020 The Guilford Press
A Division of Guilford Publications, Inc.
370 Seventh Avenue, Suite 1200, New York, NY 10001
www.guilford.com
Chapter 6, ISTSS PTSD Prevention and Treatment Guidelines:
Methodology, and Chapter 7, ISTSS PTSD Prevention and Treatment
Guidelines: Recommendations, Copyright © 2020 International Society for
Traumatic Stress Studies
All rights reserved
No part of this book may be reproduced, translated, stored in a retrieval
system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, microfilming, recording, or otherwise, without
written permission from the publisher.
Printed in the United States of America
This book is printed on acid-free paper.
Last digit is print number: 9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
Names: Forbes, David (Clinical psychologist), editor.
Title: Effective treatments for PTSD : practice guidelines from the
International Society for Traumatic Stress Studies / edited by
David Forbes, Jonathan I. Bisson, Candice M. Monson, Lucy Berliner.
Description: Third edition. | New York : The Guilford Press, [2020] |
Includes bibliographical references and index.
Identifiers: LCCN 2019056124 | ISBN 9781462543564 (paperback) |
ISBN 9781462543571 (hardback)
Subjects: LCSH: Post-traumatic stress disorder—Treatment—Standards. |
Psychic trauma—Treatment—Standards. | Psychotherapy—Standards.
Classification: LCC RC552.P67 E35 2020 | DDC 616.85/21—dc23
LC record available at https://lccn.loc.gov/2019056124
About the Editors
David Forbes, PhD, is Director of Phoenix Australia Centre for Posttrau-
matic Mental Health and Professor in the Department of Psychiatry at the
University of Melbourne. He began practicing as a clinical psychologist in
the mid-1990s and has a strong research track record in the assessment and
treatment of mental health problems in trauma survivors, with a speciality
in military, veteran, emergency services, and post-disaster mental health.
Dr. Forbes led the development of the Australian Guidelines for the Treat-
ment of Acute Stress Disorder and PTSD and is Co-Chair of the 5-Eyes Men-
tal Health Research and Innovation Collaboration.
Jonathan I. Bisson, DM, FRCPsych, is Professor of Psychiatry at Cardiff
University School of Medicine, Wales, United Kingdom, and a practicing
psychiatrist. He is Chair of the Treatment Guidelines Committee of the
International Society for Traumatic Stress Studies and is currently develop-
ing an All Wales Traumatic Stress Quality Improvement Initiative. Dr. Bis-
son was Co-Chair of the first PTSD Guideline Development Group of the
United Kingdom’s National Institute for Health and Care Excellence. He is
a past president of the European Society for Traumatic Stress Studies and
led the development of Veterans NHS Wales. He has conducted widely cited
research on the prevention and treatment of PTSD.
Candice M. Monson, PhD, is Professor of Psychology at Ryerson University
in Toronto, Ontario, Canada. She is President-Elect of the International Soci-
ety for Traumatic Stress Studies and is a Fellow of the American and Cana-
dian Psychological Associations, the Association for Behavioral and Cogni-
tive Therapies, and the Royal Society of Canada. Dr. Monson is a foremost
v
vi About the Editors
expert on traumatic stress and the use of individual and conjoint therapies
to treat PTSD. She is coauthor of Cognitive Processing Therapy for PTSD and
Cognitive-Behavioral Conjoint Therapy for PTSD and coeditor of Effective Treat-
ments for PTSD, Third Edition, among other books.
Lucy Berliner, MSW, is Director of the Harborview Center for Sexual
Assault and Traumatic Stress at the University of Washington, where she
is also Clinical Associate Professor in the School of Social Work and in the
Department of Psychiatry and Behavioral Sciences. Her activities include
clinical practice with child and adult victims of trauma and crime; research
on the impact of trauma and the effectiveness of clinical and societal inter-
ventions; and participation in local and national social policy initiatives to
promote the interests of trauma and crime victims.
Contributors
Eva Alisic, PhD, Child and Community Wellbeing Unit, School of Population
and Global Health, University of Melbourne, Melbourne, Australia
Sudie E. Back, PhD, Department of Psychiatry and Behavioral Sciences,
Medical University of South Carolina, Charleston, South Carolina
Lucy Berliner, MSW, Harborview Abuse and Trauma Center, Seattle, Washington
Jonathan I. Bisson, DM, FRCPsych, Department of Psychological Medicine
and Clinical Neurosciences, School of Medicine, Cardiff University,
Cardiff, Wales, United Kingdom
Chris R. Brewin, PhD, Department of Clinical, Educational, and Health Psychology,
University College London, London, United Kingdom
Richard A. Bryant, PhD, School of Psychology, University of New South Wales,
Sydney, Australia
Mark Burton, PhD, Department of Psychiatry and Behavioral Sciences,
Emory University School of Medicine, Atlanta, Georgia
Kathleen M. Chard, PhD, Trauma Recovery Center, Cincinnati VA Medical Center
and Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati,
Cincinnati, Ohio
Kelly Chrestman, PhD, Center for Deployment Psychology, Department of Medical
and Clinical Psychology, Uniformed Services University of the Health Sciences,
Bethesda, Maryland
Marylene Cloitre, PhD, National Center for PTSD, Palo Alto VA Health Care
Services, Palo Alto, California; Department of Psychiatry and Behavioral Sciences,
Stanford University, Stanford, California
Judith Cohen, MD, Department of Psychiatry, Drexel University College of Medicine,
Pittsburgh, Pennsylvania
Zachary Cohen, PhD, National Center for PTSD, Palo Alto, California; Department
of Psychiatry, University of California, Los Angeles, Los Angeles, California
Rowena Conroy, PhD, School of Psychological Sciences, University of Melbourne,
Melbourne, Australia
vii
viii Contributors
Andrea Danese, MD, PhD, Department of Child and Adolescent Psychiatry,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London,
London, United Kingdom
JoAnn Difede, PhD, Department of Psychology, Weill Cornell Medicine,
New York, New York
Shannon Dorsey, PhD, Department of Psychology, University of Washington,
Seattle, Washington
Grete Dyb, MD, PhD, Norwegian Centre for Violence and Traumatic Stress Studies
and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
Anke Ehlers, PhD, Oxford Centre for Anxiety Disorders and Trauma, Department
of Experimental Psychology, University of Oxford, Oxford, United Kingdom
Edna B. Foa, PhD, Center for the Study and Treatment of Anxiety, Department
of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
David Forbes, PhD, Phoenix Australia Centre for Posttraumatic Mental Health
and Department of Psychiatry, University of Melbourne, Melbourne, Australia
Julian D. Ford, PhD, ABPP, Center for Trauma Recovery and Juvenile Justice,
Center for the Treatment of Developmental Trauma Disorders, and Department
of Psychiatry, University of Connecticut Health Center, Farmington, Connecticut
Tara E. Galovski, PhD, National Center for PTSD, VA Boston Healthcare System,
and Department of Psychiatry, Boston University School of Medicine,
Boston, Massachusetts
Jaimie Gradus, DSc, MPH, Department of Epidemiology, Boston University School
of Public Health; and Department of Psychiatry, Boston University School
of Medicine, Boston, Massachusetts
Mathew D. Hoskins, MBBCh, MSc, MRCPsych, Division of Psychological Medicine
and Clinical Neurosciences, School of Medicine, Cardiff University,
Cardiff, Wales, United Kingdom
Lisa Jaycox, PhD, RAND Corporation, Arlington, Virginia
Tine Jensen, PhD, Department of Psychology, University of Oslo, and Norwegian
Centre for Violence and Traumatic Stress Studies, Oslo, Norway
Tammy Jiang, MPH, Department of Epidemiology, Boston University School
of Public Health, Boston, Massachusetts
Thanos Karatzias, PhD, School of Health and Social Care, Edinburgh Napier
University, and NHS Lothian Rivers Centre for Traumatic Stress,
Edinburgh, United Kingdom
Nancy Kassam-Adams, PhD, Department of Pediatrics, University
of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
Debra L. Kaysen, PhD, Department of Psychiatry and Behavioral Sciences,
Stanford University Medical Center, Palo Alto, California
Justin Kenardy, PhD, School of Psychology, University of Queensland,
Queensland, Australia
Karestan C. Koenen, PhD, Departments of Epidemiology and Social
and Behavioral Sciences, Harvard T. H. Chan School of Public Health,
Cambridge, Massachusetts
Contributors ix
Kristina J. Korte, PhD, Department of Psychiatry, Massachusetts General Hospital,
Boston, Massachusetts
Ariel J. Lang, PhD, MPH, VA San Diego Center for Excellence for Stress
and Mental Health and Departments of Psychiatry and Family Medicine
and Public Health, University of California, San Diego, San Diego, California
Christopher Lee, PhD, Faculty of Health and Medical Sciences, University
of Western Australia, Perth, Australia
Catrin Lewis, PhD, Division of Psychological Medicine and Clinical Neurosciences,
School of Medicine, Cardiff University, Cardiff, Wales, United Kingdom
Andreas Maercker, MD, PhD, Department of Psychopathology and Clinical
Intervention, University of Zurich, Zurich, Switzerland
Sybil Mallonee, PhD, Department of Medical and Clinical Psychology, Uniformed
Services University of the Health Sciences, Bethesda, Maryland
Jessica Maples-Keller, PhD, Department of Psychiatry and Behavioral Sciences,
Emory University School of Medicine, Atlanta, Georgia
Ifigeneia Mavranezouli, MD, Research Department of Clinical, Educational
and Health Psychology, University College London, London, United Kingdom
Richard Meiser-Stedman, PhD, Department of Clinical Psychology
and Psychological Therapies, University of East Anglia, Norwich, United Kingdom
Cathrine Mihalopoulos, PhD, School of Health and Social Development,
Deakin University, Geelong, Australia
Candice M. Monson, PhD, Department of Psychology, Ryerson University, Toronto,
Ontario, Canada
Kim T. Mueser, PhD, Center for Psychiatric Rehabilitation, Boston University,
Boston, Massachusetts
Laura K. Murray, PhD, Department of Mental Health, Johns Hopkins
Bloomberg School of Public Health, Baltimore, Maryland
Barbara Niles, PhD, National Center for PTSD, VA Boston Healthcare System,
and Department of Psychiatry, Boston University School of Medicine,
Boston, Massachusetts
Reginald D. V. Nixon, PhD, College of Education, Psychology and Social Work,
Flinders University, Adelaide, Australia
Meaghan L. O’Donnell, PhD, Phoenix Australia Centre for Posttraumatic
Mental Health and Department of Psychiatry, University of Melbourne,
Melbourne, Australia
Miranda Olff, PhD, Department of Psychiatry, Amsterdam University
Medical Centers, University of Amsterdam, Amsterdam, Netherlands;
ARQ National Psychotrauma Centre, Diemen, Netherlands
Belinda J. Pacella, MClinPsych, Phoenix Australia Centre for Posttraumatic
Mental Health and Department of Psychiatry, University of Melbourne,
Melbourne, Australia
Stephen Pilling, PhD, Division of Psychology and Language Sciences,
University College London, London, United Kingdom
x Contributors
David S. Riggs, PhD, Center for Deployment Psychology, Department of Medical
and Clinical Psychology, Uniformed Services University of the Health Sciences,
Bethesda, Maryland
Neil P. Roberts, DClinPsy, Cardiff and Vale University Health Board and Division
of Psychological Medicine and Clinical Neurosciences, School of Medicine,
Cardiff University, Cardiff, Wales, United Kingdom
Craig Rosen, PhD, National Center for PTSD, VA Palo Alto Health Care System,
Menlo Park, California
Rita Rosner, DPhil, DiplPsych, Department of Psychology, Catholic University
of Eichstätt-Ingolstadt, Eichstätt, Germany
Barbara O. Rothbaum, PhD, ABPP, Emory Healthcare Veterans Program
and Department of Psychiatry and Behavioral Sciences, Emory University School
of Medicine, Atlanta, Georgia
Mark C. Russell, PhD, School of Applied Psychology, Counseling and Family
Therapy, Antioch University, Seattle, Washington
Ulrich Schnyder, MD, Department of Consultation-Liaison Psychiatry
and Psychosomatic Medicine, University Hospital, University of Zurich,
Zurich, Switzerland
Sarah J. Schubert, PhD, private practice, Brentwood, Australia
Francine Shapiro, PhD (deceased), Mental Research Institute, Palo Alto,
California; EMDR Institute, Watsonville, California
Marit Sijbrandij, PhD, Department of Clinical, Neuro, and Developmental
Psychology and WHO Collaborating Centre for Research and Dissemination
of Psychological Interventions, Vrije University Amsterdam, Amsterdam, Netherlands
Dan J. Stein, FRCPC, PhD, SA MRC Unit on Risk & Resilience in Mental Disorders,
Department of Psychiatry and Neuroscience Institute, University of Cape Town,
Cape Town, South Africa
Shannon Wiltsey Stirman, PhD, National Center for PTSD, VA Palo Alto
Health Care System, Menlo Park, California; Department of Psychiatry
and Behavioral Sciences, Stanford University, Palo Alto, California
Yilang Tang, MD, PhD, Department of Psychiatry and Behavioral Sciences,
Emory University School of Medicine, and Atlanta VA Medical Center,
Atlanta, Georgia
Larissa Tate, MS, MPS, Department of Medical and Clinical Psychology,
Uniformed Services University of the Health Sciences, Bethesda, Maryland
Siri Thoresen, PhD, Norwegian Centre for Violence and Traumatic Stress Studies
and Department of Psychology, University of Oslo, Oslo, Norway
Maegan M. Paxton Willing, BS, Department of Medical and Clinical Psychology,
Uniformed Services University of the Health Sciences, Bethesda, Maryland
Laurence Astill Wright, MBBCH, Division of Psychological Medicine
and Clinical Neurosciences, School of Medicine, Cardiff University,
Cardiff, Wales, United Kingdom
Katarzyna Wyka, PhD, Department of Psychiatry, Weill Cornell Medicine,
New York, New York
A Note from the Editors
of the Second Edition
C ongratulations to Dave Forbes, Jon Bisson, Candice Monson, and Lucy
Berliner on overseeing this new edition. They have masterfully synthe-
sized the wide-ranging research on treating posttraumatic stress disorder
that has been conducted since the publication of the second edition in 2009.
Their editorial vision has brought a fresh perspective to the treatment guide-
lines of the International Society for Traumatic Stress Studies and offers the
field an invaluable resource. We are thrilled to see the careful work in this
arena continue, giving guidance to practitioners and researchers around the
world.
Edna B. Foa
Terence M. K eane
M atthew J. F riedman
Judith A. Cohen
xi
Preface
C linical practice guidelines, which synthesize research evidence to gen-
erate specific treatment recommendations for a particular disorder,
have been of crucial importance over the last decade in promoting a shift
toward evidence-based care. Clinical practice guidelines for posttraumatic
stress disorder (PTSD) are designed primarily to help clinicians achieve
improved mental health outcomes for people affected by trauma. The sec-
ondary goal is to assist those people and their families, as well as policy-
makers and service delivery organizations, to develop a more sophisticated
understanding of the range of available treatments and the evidence for
their efficacy.
The recent Posttraumatic Stress Disorder Prevention and Treatment Guide-
lines, on which this book is based, were published by the International Soci-
ety for Traumatic Stress Studies (ISTSS) in 2018, with earlier versions dating
back to 2000 and 2009 (as well as guidelines for the treatment of complex
PTSD in 2012). The latest guidelines build on the groundbreaking work of
the initial guidelines through adopting a standardized rigorous systematic
review of the available research literature across all the areas of focus. Simi-
lar evidence-driven guidelines for PTSD treatment have been published in
several countries, including Australia, the United Kingdom, and the United
States, with all arriving at largely similar conclusions. Although the high
degree of consensus is reassuring, this methodological approach to guide-
line development comes at a price. A heavy reliance on randomized con-
trolled trials means that other less rigorous but perhaps equally important
sources of data, as well as the nuances of clinical practice, may not be con-
sidered in generating recommendations.
xii
Preface xiii
Perhaps more important, the challenge for clinicians is often one of
how to apply the recommendations in the real world of clinical practice. It
is one thing to know what the research evidence tells us about treatments
that work. It is another thing altogether to implement those treatments in
routine clinical practice, frequently in the context of significant clinical com-
plexity, psychosocial disadvantage, and limitations in mental health delivery
systems. Clinicians may question whether the findings from sophisticated
research trials are translatable to their everyday clinical practice. They may
question their own ability to deliver those evidence-based interventions and,
perhaps, to contain any distress that might be triggered by trauma-focused
psychological interventions.
Using the latest ISTSS PTSD guidelines as the starting point, each chap-
ter of this book summarizes the research evidence base and resulting recom-
mendations reported in those guidelines. While keeping the empirical find-
ings front and center in driving the treatment recommendations, the book
stands as a natural evolution of the science by explaining not only how the
research foundations were derived but also how those findings were used to
form the basis of the recommendations.
The book goes on to bridge the gap between evidence-based guidelines
and routine practice in the real world. It is a unique contribution to the
field, with each chapter going beyond the research evidence to explore the
challenges of implementation. The authors, all specialists in their specific
treatment approaches, were asked to build on the recommendations by con-
sidering the common difficulties encountered by clinicians across a diverse
range of settings and with a broad range of trauma-affected populations.
They were encouraged to explore when and why things go wrong in treat-
ment, why some people do not respond, how we might decide to stop trying
a particular approach, and what to do at that point. The treatment chapters
are preceded by contextual chapters that outline recent developments in our
understanding of the nature, epidemiology, and assessment of mental health
responses to trauma exposure in adults, adolescents, and children, as well
as the latest evidence on prevention. Following the treatment chapters, the
book goes on to foreshadow future developments in areas such as transdiag-
nostic conceptualizations of posttraumatic mental health problems, tailor-
ing treatment to the unique needs of the individual clinical presentation,
dissemination challenges, and economic implications.
In focusing on the practical aspects of guideline implementation for
clinicians, therefore, the authors recognize the limitations of the research
and go beyond it to provide practical, clinically informed advice on how best
to use and understand the recommendations in a way that is accessible and
useful for clinicians and health service agencies.
After reading this book, clinicians will be clear about not only the spe-
cific treatment recommendations for PTSD, but also how to implement them
in varying environments and with complex clinical presentations. They will
understand where the field is heading in terms of clinical practice, research,
xiv Preface
and implementation science. By striving to adopt the advice provided by the
expert clinicians who have authored each chapter, readers will become part
of that journey as the field continues to develop. They will be up to date on
the latest thinking in the treatment of PTSD, making them a point of refer-
ence for those who practice around them and leaders in the field among
their clinical colleagues. In short, this book is essential reading for all clini-
cians working with survivors of trauma.
David Forbes, PhD
Jonathan I. Bisson, DM, FRCPsych,
Candice M. Monson, PhD
Lucy Berliner, MSW
Acknowledgments
We would like to acknowledge that this third edition of Effective Treatments
for PTSD sits on the shoulders of the work of previous editors of the first and
second editions of this book, Edna Foa, Terrence Keane, Matthew Friedman,
and Judith Cohen. Without their field leadership and insight represented in
the first two editions, this volume would not have been possible.
This book is founded on the Posttraumatic Stress Disorder Prevention
and Treatment Guidelines of the ISTSS. We thank the entire PTSD Guide-
lines Committee for their work in developing the guidelines. The commit-
tee included Jonathon I. Bisson (Chair), David Forbes (Vice Chair), Lucy
Berliner, Marylene Cloitre, Lutz Goldbeck, Tine Jensen, Catrin Lewis,
Candice M. Monson, Miranda Olff, Stephen Pilling, David S. Riggs, Neil P.
Roberts, and Francine Shapiro. The editors of this volume and the PTSD
Guidelines Committee acknowledge the passing of our friends and col-
leagues in this work, Dr. Lutz Goldbeck and Dr. Francine Shapiro, both of
whom contributed enormously through their work to reduce the suffering
of people with PTSD.
