Posttraumatic Stress Disorder: Developments in Assessment and Treatment

1. Narration of the traumatic event. This is the single most essential component, besides the underlying therapeutic alliance, and there are many effective ways for therapists to facilitate the narrative process. These include imaginal exposure (as in PE), a linear life narrative approach (as in narrative exposure therapy [NET]), visualization of the traumatic event (as in eye movement desensitization and reprocessing [EMDR]), written narration (shown to be equivalent to the full manualized CPT package in a dismantling study26), facilitation through virtual reality, and inherent narrative processes built into all forms of trauma-focused psychotherapies. ^15,16
2. Cognitive restructuring. This may be delivered in a systematized manner, such as in CPT or EMDR, or more organically, as occurs in PE or NET. Cognitive restructuring, which fundamentally involves gaining a different perspective on the traumatic event(s) and one’s responses (eg, coming to terms with guilt, self-blame, or pervasive mistrust), often emerges naturally during narrative processes.
3. In-vivo exposure. This involves graded exposure to activities that trigger symptoms, such as being able to shop at a grocery store during peak hours. Invivo exposure is an inherent component of many trauma-focused treatments, including PE and Stress Inoculation Training. In-vitro techniques that rely on visualization (eg, EMDR) provide another viable delivery method.
4. Relaxation exercises . Aimed at addressing physiologic reactivity, these can include diaphragmatic breathing, progressive muscle relaxation, mindfulness, eye movements, and various other approaches, including simply bringing greater awareness to the level of distress through routine
   use of a subjective distress measure.
5. Psychoeducation. This provides an understanding of why PTSD occurs and the underlying physiologic mechanisms and correlates, including the effects of trauma on neuroendocrine and autonomic nervous system regulation, and the strong association of PTSD with physical health effects. Tailoring psychoeducation to military and veteran populations is critical, because of the occupational context in which PTSD can occur and the fact that PTSD symptoms are rooted in skills and responses that are adaptive and beneficial in military occupational and war-zone environments. ¹⁶

Complementary and alternative medicine approaches also have a role in augmenting evidence-based PTSD treatment, for example, through facilitating relaxation responses, helping with chronic pain or sleep, or facilitating narrative processes through expressive arts. ²⁷

New Developments in Psychotherapy

In terms of new developments, 2 trauma-focused psychotherapies deserve particular consideration. The first is NET, which has been shown to be highly effective in severely traumatized populations and has even been delivered by lay counselors with only a few weeks of training. ²⁸ Narrative exposure therapy has a solid evidence base, is within the A-level exposure therapy category in the VA/DoD CPG, is simple and straightforward in its approach, easy to learn, and specifically designed for multiple traumas, which can be very relevant to military and veteran populations. However, NET is almost never used by clinicians in DoD and VA facilities. In addition to offering it as a treatment option in DoD and VA mental health clinics, research is needed to explore the potential use of NET to reach veterans who do not engage in traditional care but may be willing to receive services in primary care or even nonmedical settings through peerto-peer models.