The Use of Both Prolonged Exposure and Cognitive Processing Therapy in the Treatment of a Person With PTSD,Multiple Traumas,Depression,and Suicidality

1 Theoretical and Research Basis for Treatment

Posttraumatic stress disorder (PTSD) has an estimated lifetime prevalence of 6.8% to 8.7% in the U.S. adult population and is characterized by several key symptoms including negative alterations in cognition or mood (e.g., feelings of detachment and/or inability to experience positive emotion), and changes in arousal and reactivity (e.g., irritability, hypervigilance, exaggerated startle response; American Psychiatric Association, 2013; Kessler, Berglund, Demler, Jin, & Walters, 2005). There is also a high prevalence rate of comorbid psychiatric disorders associated with PTSD (Gadermann, Alonso, Vilagut, Zaslavsky, & Kessler, 2012). Major depressive disorder (MDD) is one of the most common co-occurring disorders with approximately 30% to 52% of individuals with PTSD also meeting criteria for MDD (Angelakis & Nixon, 2015; Rytwinski, Scur, Feeny, & Youngstrom, 2013). When compared with individuals who have PTSD alone, comorbid PTSD/MDD is associated with greater symptom severity, greater subjective distress and impairment, greater dissociation, poorer social and occupational functioning, and poorer prognosis and response to treatment (Bedard-Gilligan et al., 2015; Campbell et al., 2007; Rytwinski et al., 2013). There is also a strong relationship between PTSD and an increased risk for suicidal thoughts and behaviors (Campbell et al., 2007). Prior literature suggests that the presence of MDD not only contributes to a more complicated and severe PTSD presentation but also compounds the risk of suicidality in individuals with PTSD (Oquendo et al., 2003; Tarrier & Gregg, 2004). However, despite the high prevalence rates of both MDD and suicidality in PTSD populations, the clinical guidelines on how to most effectively treat patients that present with these issues are scarce.

Prolonged exposure (PE), cognitive processing therapy (CPT), stress inoculation training (SIT), and eye-movement desensitization and reprocessing (EMDR) are considered the frontline PTSD treatments by the U.S. Department of Veteran Affairs (VA)/Department of Defense (Steenkamp & Litz, 2013). Although each has its own empirical support, PE is the most widely researched, has demonstrated effectiveness regardless of the type of trauma, and was found to be the only efficacious PTSD treatment by the Institute of Medicine (IOM; 2007; van Minnen, Harned, Zoellner, & Mills, 2012). Thus, PE is considered the “gold standard” treatment for PTSD (Rauch, Eftekhari, & Ruzek, 2012).

However, with regard to individuals who present to treatment with PTSD and comorbid concerns, there seems to be a reluctance to research and treat more complicated PTSD cases due to the commonly held belief that treating PTSD in these patients will exacerbate co-occurring conditions (van Minnen et al., 2012; van Minnen, Zoellner, Harned, & Mills, 2015). Some clinicians report believing that trauma treatments are contraindicated for patients with comorbid conditions or that certain patients are “too fragile” for trauma-focused treatment (Hamblen, Schnurr, Rosenberg, & Eftekhari, 2009; van Minnen et al., 2012). This is especially true with PE as it is commonly believed to be a stressful and intense treatment that may not be well-tolerated by individuals with more complicated PTSD presentations. However, a small yet growing body of literature does not support this assertion (Hamblen et al., 2009). Instead, it suggests that comorbid conditions actually remain the same or concurrently improve during the treatment of PTSD (van Minnen et al., 2015). For example, Hagenaars, van Minnen, and Hoogduin (2010) demonstrated that patients with severe depressive symptoms obtained similar benefit from exposure treatments when compared with patients without these concerns. In addition, although clinicians are advised not to begin treatment with patients who are acutely suicidal, preliminary findings suggest that PE can be used safely and effectively with patients presenting with low-to-moderate suicidality behaviors or concerns (Harned & Linehan, 2008; Steenkamp & Litz, 2013; van Minnen et al., 2012; van Minnen et al., 2015). It is also important to note that the extant literature demonstrates that PE does not exacerbate suicidality, and there are no documented completed suicides during PE studies (van Minnen et al., 2015). Until recently, no trauma-focused treatments addressed suicidal/self-injuring behaviors in PTSD patients. However, Harned and colleagues created an integrated treatment modality comprised of exposure therapy and dialectical behavior therapy to specifically address both symptoms of PTSD and suicidal/self-injurious behaviors in women with borderline personality disorder (Harned, Korslund, Foa, & Linehan, 2012; Harned & Linehan, 2008). Women in their samples experienced significant improvements in PTSD symptoms, suicidal behaviors and urges, dissociation, depression, anxiety, and trauma-related guilt and shame (Harned et al., 2012; Harned & Linehan, 2008).

Several additional studies suggest that integrated treatment approaches, which include non-exposure-based therapy techniques, may be more tolerable to individuals with more complicated PTSD presentations and may also be perceived as more acceptable by clinicians (Kehle-Forbes et al., 2013). While some studies suggest that combined treatments do not enhance treatment outcomes (e.g., Foa, Dancu, et al., 1999; Foa et al., 2005), there are no studies to date that show iatrogenic effects due to the addition of other treatment techniques. In other words, the addition of other treatment components does not lessen the efficacy of exposure-based treatments nor does it have detrimental effects on the patient or patient outcomes (Kehle-Forbes et al., 2013). In fact, several studies which utilized integrated treatments have demonstrated significant improvements in PTSD, depression and anxiety symptoms, and overall mental health functioning (e.g., Steenkamp et al., 2011; Strachan, Gros, Ruggiero, Lejuez, & Acierno, 2012). Interestingly, two case studies utilized a combination of imaginal, in-vivo, and interoceptive exposure therapy (Wald & Taylor, 2010) or a combination of PE, mindfulness, and emotion regulation skills (Frye & Spates, 2012), and both individuals demonstrated significant improvements in PTSD, MDD, anxiety sensitivity, and emotion regulation skills.

Furthermore, three studies suggest that, when compared with singular treatments alone, integrated approaches can lead to improved patient outcomes. In a randomized control trial (RCT) conducted by Cloitre et al. (2010), women with childhood-abuse-related PTSD who received skills training in affect and interpersonal regulation (STAIR) + exposure experienced greater improvements in PTSD symptoms, emotion regulation, and interpersonal problems when compared with women in either of the two control conditions (supportive counseling + exposure or STAIR only). In another RCT that compared eight individual sessions of (a) imaginal exposure (IE), (b) in-vivo exposure (IVE), (c) IE + IVE, or (d) IE + IVE + cognitive restructuring (CR) in a sample of nonmilitary trauma survivors, Bryant et al. (2008) found the largest effect sizes and reductions in symptoms of PTSD and depression in those who received IE + IVE + CR, which suggests that CR provided additive gains to exposure therapy. Cigrang et al. (2011) incorporated elements of CPT into PE treatment and found significant improvements in PTSD, depression, and global mental health functioning in active-duty military members. Taken together, results from these three studies seem to support the idea of incorporating or augmenting the CR and skills-training components of trauma-focused treatments.

Despite promising preliminary results from the aforementioned studies that utilized integrative approaches, there continues to be a lack of empirical guidelines for how to effectively treat PTSD in the context of complicating factors. The current case demonstrates how we handled a complicated clinical presentation (i.e., severe depression, multiple traumas), began treatment with PE, managed suicidality concerns when they arose mid-treatment, and traversed between two treatment modalities (PE and CPT). Results lend further support to the use of an integrated approach, which appeared to be well-tolerated by the client and led to improvements in PTSD, depression, anxiety, and suicidal ideations, which continued to improve 3 and 6 months post treatment.

2 Case Introduction

Amanda* (name changed to ensure confidentiality), a self-referred, 28-year-old, married, Caucasian female, presented with symptoms of anxiety and depression, which began 8 months prior when she lost her job (of 6 months) as a receptionist at a chiropractic office. At the intake, Amanda met criteria for MDD (recurrent episodes, current, severe with anxious features) and PTSD due to a history of multiple traumas including rapes at ages 18 and 21 and threatened physical abuse from her father from the ages of 10 to 13. Amanda’s father suffered from untreated bipolar disorder and completed suicide when she was 13 years old.

3 Presenting Complaints

Amanda reported that since losing her job 8 months prior to presenting to treatment, she had been experiencing symptoms of depression including uncontrollable crying, very sad mood, lack of motivation, anhedonia, insomnia, upset stomach, loss of appetite, and feeling as if she was in a “pit.” The symptoms had reportedly worsened in the month prior to presenting to treatment. Amanda also reported that approximately 1 month prior to initiating treatment, she began experiencing anxiety symptoms (with no known precipitants) of difficulty breathing, feeling flustered, being unable to relax, and being awoken in the middle of the night with a racing heart. These problems were significantly interfering with Amanda’s daily life and social relationships. Although unemployed, Amanda’s depression made it difficult for her to find the motivation to search and apply for jobs. Amanda reported that she found it difficult to attempt to make friends, so spent most of her time with her husband of 3 years.

Amanda hoped that, by processing her trauma history in a therapeutic setting, she would be able to see how the traumatic events had influenced her behaviors and ways of thinking. Amanda’s additional goals for treatment included improving her self-esteem, reducing her symptoms of anxiety and depression, learning to love herself, and thinking in a more positive way.

4 History

Amanda reported being a bright and confident child until the age of 10 or 11. She indicated that she was a “daddy’s girl” and that her father was her role model. She described her father as loving, fun, social, active, and attentive toward his family. However, Amanda explained that when she was 10 or 11, her father gradually became short-tempered. He would often come home enraged, hitting walls, throwing things, and threatening to hurt Amanda, her younger sister, and their mother. Amanda denied being physically injured by her father but endorsed many “close calls.” She recalled one instance in which he pinned her against a cabinet, attempted to punch her in the face, but missed, and ended up punching the cabinet. Amanda stated that on occasion, her mother would intervene to defend her children. She denied any instances in which her father physically injured her sister or mother. Amanda reported living in fear and, as such, loved going to school because she did not feel safe at home. While it is unclear whether Amanda’s father struggled with substance abuse or alcoholism, Amanda reported that her father suffered from untreated bipolar disorder. When Amanda was 13 years old, her father completed suicide by poisoning himself. She did not witness the event or see her father’s dead body. Shortly after her father’s suicide, Amanda was diagnosed with depression (age 14). At the time of intake, Amanda continued to struggle with the memories of her father and had difficulty reconciling the memories of him before and after his mental illness. She also endorsed feeling as if his suicide was a choice to leave or abandon the family and she often wondered why he did not choose them. Amanda reported feelings of guilt and wondering whether some of her actions (e.g., the way she had spoken to him) had influenced his suicide.

Amanda began dating at age 14. At age 16, she began a 2.5-year relationship she described as “tumultuous.” At age 18, she reported that her boyfriend forcibly raped her. She reported that despite telling him “no,” and kicking, scratching, and biting him, he continued. He later insisted that he thought she was engaging in role-playing. She stated that she remained in the relationship for an additional 6 months until, following an argument, he slapped her across the face with so much force that she fell to the ground. Amanda reported that the boyfriend had hit her a few times before (e.g., slapped her on the back with so much force that it bruised) but she did not break up with him until the incident in which he slapped her across the face.

At age 21, Amanda reconnected with a male friend from high school who “was like a brother” to her. On her 21st birthday, she went out with a group of friends and invited the male friend. As he was unable to drive home at the end of the night due to his inebriation, Amanda told him he could stay at her house. Once home, the male friend suddenly kissed her. Amanda refused and insisted she thought of him as a friend only. Amanda is unable to remember details following her refusal and reports feeling as if she blacked out or went in shock. Her memory returned to a moment when she realized he was raping her. He had her pinned to the bed so that she was unable to move, and she recalled repeatedly saying “no” and “stop.” She reported being paralyzed with fear and thinking, “If he is capable of this, there is no telling what he could do.” Amanda reported being in shock and staring at the ceiling for the rest of the night, unable to move. She stated that he left in the morning and she remained in shock for approximately 1 week. She reported the incident to the police 1 week following the event and decided to press charges. However, a day before the trial, the hearing was canceled and all charges were dropped. Amanda believes that he knew someone in the system and paid them off. Following the cancelation of the trial, Amanda attempted suicide. She reportedly overdosed on several medications that were in her home. She stated that a friend happened to call her after she had taken the pills and because Amanda’s speech was slurred, the friend called her family, who found her and called 911. Amanda reported that she did not need to have her stomach pumped as she had vomited the medications prior to the paramedics arriving. Amanda was under observation at the hospital for 1 week. Amanda denied any other suicide attempts. At the intake, Amanda denied any current suicidal ideations, thoughts, or plans. Although she reported that, at times, she felt like a burden to her loved ones, she had made a promise to herself to never attempt suicide again.

At the intake, Amanda endorsed numerous PTSD symptoms and met Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) criterion A through H. Although DSM-IV-TR was being used at the time of Amanda’s treatment, she would have met Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) criteria as she endorsed experiencing symptoms of reexperiencing, arousal, avoidance, and persistent negative alterations in cognitions and mood. She reported that she had experienced these symptoms since age 21 and that some of her symptoms even began at age 18 years. Amanda endorsed experiencing physiological symptoms when something reminded her of the trauma(s), always feeling “extra alert” or hypervigilant, having an exaggerated startle response, experiencing frequent nightmares, not being able to remember a part of the trauma, feeling emotionally “numb,” experiencing persistent irritability, and holding beliefs such as, “the world is not a safe place” and “you can never fully trust people.” She endorsed being most distressed by the rape that occurred at age 21 stating that this incident “crushed my whole world.” She reported that she was no longer sure who she could trust as the perpetrator (a long-time friend) was someone that she thought she knew. She also endorsed having a lot of self-blame as she had “put herself in that situation.” Although it was difficult for Amanda to trust men, she was able to put aside her fears for the relationship with her husband. However, she reported that she felt “vulnerable” and “uncomfortable” during sexual intimacy.

Amanda reported seeing a series of psychologists on and off throughout the years, but denied ever receiving trauma-focused treatment. Although Amanda had taken antidepressant medication since she was diagnosed with depression at age 14 (Effexor, dosage unknown), at the time of intake, she had not taken medication for about 5 years as she felt she no longer needed it.

5 Assessment

Amanda’s pretreatment intake evaluation included modules from the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID; First, Spitzer, Gibbon, & Williams, 2002) and the SCID for Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) Axis II Personality Disorders (SCID-II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997), and several self-report measures including the Dissociative Experiences Scale (DES), Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), and the PTSD Symptom Scale (please see detailed descriptions in the “Self-Report Measures” section below). Clients are referred out for a higher level of care if they have active suicidal ideations, severe borderline personality disorder, or DES scores of 30 or higher, suggestive of a dissociative disorder. At the time of intake, Amanda denied any current suicidal ideations, did not meet criteria for borderline personality disorder, and had a DES score of 14. Although Amanda had a previous suicide attempt at age 21, her strong marriage and social support from her husband mitigated this risk and allowed her to be accepted for treatment.

Per the results of Amanda’s intake evaluation, she met diagnostic criteria for MDD with a current, severe episode as she endorsed numerous depressive symptoms (e.g., anhedonia, loss of appetite) and had experienced these symptoms for 8 months prior to intake. Amanda met criteria for the anxious distress specifier as she presented with difficulty breathing, racing heart, feeling flustered, and inability to relax. She also met criteria for PTSD, as she had experienced numerous symptoms for years (e.g., hypervigilance, nightmares).

Amanda’s progress throughout treatment was tracked utilizing the BDI-II, BAI, PTSD Symptom Scale, and the Posttraumatic Cognitions Inventory (PTCI), approximately every other week during treatment, at termination, and at 3- and 6-month follow-up post treatment. It should be noted that the PTCI was added as an additional measure to track progress approximately midway through treatment (when CPT began). Please see Table 1 for total scores at each evaluation time point. Furthermore, during the active PE sessions, Amanda’s subjective distress was measured by the Subjective Units of Distress Scale (SUDS; see below for description). Amanda’s SUDS ratings throughout the active PE sessions are displayed in Figure 1.

OPEN IN VIEWER

Table 1.

Progress During Treatment.

Notable time points	Prep phase		Active PE		Amanda has suicidal thoughts	Coping skills and restabilization phase			CPT phase		Post-CPT return to PE	Proposed term	Termination	3 months follow-up	6 months follow-up
Session	1stevaluation	2	4	6	8	12	14	16	18	20	23	27	29	30	31
BDI-II	43	25	28	19	40	25	26	22	21	22	17	22	18	11	5
BAI	29				36	28	26	19	16	9	12	14	11	5	3
PTSD scale (total score)	36			30					22	12	14	14	12	6	2
PTCI (total score)									129	103	72	69	58	40	43
PTCI (Self)									3.29	2.91	1.95	1.90	1.52	1	1.19
PTCI (World)									4.57	3.86	2.43	2.29	2.14	1.57	1.57
PTCI (Self-Blame)									3.60	1.80	2.0	2.00	1.80	1.20	1

Note. PE = prolonged exposure; CPT = cognitive processing therapy; BDI-II = Beck Depression Inventory-II; BAI = Beck Anxiety Inventory; PTCI = Posttraumatic Cognitions Inventory; PTCI (Self) = negative cognitions about self score on the PTCI; PTCI (World) = negative cognitions about world score on the PTCI; PTCI (Self-Blame) = Self-Blame subscale of the PTCI.

OPEN IN VIEWER

Figure 1.

Active PE Sessions 1-9.

6 Case Conceptualization

Because PE has demonstrated effectiveness and efficacy across a variety of traumas, it was deemed appropriate for all of Amanda’s traumatic events. PE is based on two primary strategies: repeated and prolonged IE (reliving the trauma) and IVEs (Foa, Hembree, & Dancu, 2002). Typically conducted for 30 to 60 min per therapy session, the objective of repeatedly telling one’s trauma narrative (in first person, present tense) is to improve one’s ability to process the traumatic memory (Foa et al., 2002). As individuals with PTSD typically avoid situations that remind them of the traumatic event, IVEs (usually assigned as homework) have clients confront and remain in these situations until the anxiety subsides or decreases (Foa et al., 2002). Both IEs and IVEs effectively decrease clients’ anxiety, distress, excessive fears, and avoidance behaviors (Foa et al., 2002). Clients are also taught “Breathing Retraining” as a coping strategy to “alleviate anxiety that may have been evoked by discussing the trauma” (Foa et al., 2002, p. 19). Clients are encouraged to practice the technique three times per day for 10 minutes each time (Foa et al., 2002). Therapeutic discussions following exposure sessions allow for the identification and modification of any unhelpful beliefs clients may hold, as well as the facilitation of cognitive processing, which is “considered a key component of PE” (Foa et al., 2002; Foa & McLean, 2015).

Prior to beginning PE, Amanda’s initial treatment plan included preparatory sessions to implement cognitive-behavioral techniques and create a regimen to effectively manage her depression (see Sessions 1-3 under section “Course of Treatment”). Amanda reported feeling most distressed by the rape that occurred at age 21. Thus, PE sessions began by focusing on this event. We had initially planned to have Amanda habituate to this event, select the second most distressing event, habituate, and so on. However, after four active sessions of PE, Amanda began having suicidal thoughts (see Session 8 below). Therefore, we decided to modify our initial treatment plan by suspending PE and spend time (which turned out to be 2 months) in a restabilization/coping skills phase. After Amanda stabilized, we eased back into trauma work by switching treatment modalities to CPT. Because CPT does not entail reliving the traumatic event and instead focuses on the cognitions associated with the event, it was deemed to be a less intense and potentially more tolerable treatment for Amanda. In CPT, clients are asked to write “impact statements” in which they focus not on the details of the trauma but instead on why the event happened and how the event has affected their views of themselves, others, and the world. The client and therapist then work together to identify unhelpful and/or inaccurate beliefs (“stuck points”) and attempt to modify these beliefs through therapeutic techniques such as Socratic questioning and finding evidence for or against the statements (see Resick & Schnicke, 1993 or http://cpt.musc.edu for a free CPT learning course). After six sessions of CPT and no additional suicidal ideations or distress, we returned to PE to ensure that Amanda’s distress associated with her traumatic memories had been fully cleared out. Amanda required five additional sessions of PE before she was ready for treatment termination.

7 Course of Treatment and Assessment of Progress

8 Complicating Factors

Amanda began having suicidal thoughts while undergoing PE. These thoughts were particularly concerning and needed to be addressed before continuing trauma-focused therapy. As Amanda presented to treatment with few adaptive coping skills, 2 months of treatment time were required to teach her several coping strategies and ensure that she was stabilized. After restablization and coping skills training, we felt that resuming trauma-focused treatment with CPT would be a more tolerable treatment modality before returning to PE.

It was also important for Amanda’s husband to be aware of Amanda’s suicidal thoughts during treatment and fortunately, Amanda agreed and signed a release of information that allowed her therapist to speak with him and bring him into session. However, Amanda’s therapist still needed to handle this situation in a delicate manner that felt supportive to Amanda.

In addition, Amanda presented to treatment with severe levels of depression which required careful monitoring throughout treatment. Although Amanda did not begin therapy on antidepressant medication, she was agreeable to meeting with her psychiatrist to restart Effexor-XR (75 mg) when she experienced increased depressive symptomatology and suicidal thoughts mid-treatment. Despite two unanticipated instances in which she was not taking her medication consistently (e.g., an insurance issue, and her psychiatrist halving the dosage), Amanda was very medication-compliant throughout treatment.

9 Access and Barriers to Care

Fortunately, Amanda did not experience any barriers to care. She was financially stable and could afford treatment, she owned a car and could drive herself to therapy sessions, she was motivated for treatment, and had a very loving husband who was both financially and emotionally supportive of her decision to pursue treatment. In addition, although some clinics do not treat patients with past suicide attempts, Amanda’s past suicide attempt was mitigated and she was accepted for treatment due to the abovementioned strengths.

10 Follow-Up

Follow-up assessments were conducted 3 and 6 months post treatment. At both time points, Amanda reported that things had been going very well in all domains of her life including work, social relationships, her marriage, and spirituality. She denied experiencing any relapses or suicidal thoughts. Since terminating treatment, her symptoms decreased to a minimal level (see Table 1). She reported that she has been more physically active, no longer naps after work, and is attending church and bible study regularly. Amanda has remained employed at the local elementary school and also reported instances in which she was challenged with novel tasks and rose to the occasion. She reported taking initiative at work, being proactive, continuing to engage in helpful thinking, and using CR and other coping skills when needed. In the near future, Amanda would like to go back to school to pursue a degree in Education.

11 Treatment Implications of the Case

Amanda presented to treatment with several traumatic events and had been living with undiagnosed PTSD for 10 years, as well as comorbid MDD. Amanda’s case became more complicated when she began having suicidal thoughts after the fourth active session of PE. Because there are few empirical guidelines on how to handle complicated presentations of PTSD, particularly if suicidal concerns arise mid-treatment, Amanda’s case may serve as an example of how flexibility and willingness to switch treatment focus and modality may be extremely beneficial to the client. A handful of studies have utilized integrated treatment approaches in which exposure therapy is combined with other non-exposure techniques such as CR. In line with results from these prior studies, Amanda experienced significant decreases in PTSD, depression, and anxiety symptoms. Furthermore, these studies suggest that an integrated approach may be better tolerated and viewed as more acceptable by clients and clinicians alike. Amanda’s treatment case lends further support to this view because despite severe levels of depression and suicidal thoughts, Amanda remained in treatment and continued to be compliant with the treatment plan. Amanda presented to treatment with fear and avoidance behaviors as well as many maladaptive beliefs about herself (e.g., guilt and self-blame), others (e.g., “You can never fully trust anyone.”) and the world (e.g., “The world is a dangerous place.”). Amanda appeared to benefit from both trauma-focused treatment modalities in that she was able to confront feared situations and trauma-related memories through PE, experience habituation, and challenge her unhelpful/inaccurate beliefs through CPT.

As Amanda’s case is simply one example of integrating PE, CPT, and coping skills training, it is unclear if a different sequence of events would have affected outcomes. For example, although there is no way to determine which clients may experience suicidal thoughts and when, perhaps coping skills training prior to beginning trauma-focused treatment would decrease the possibility of suicidal thoughts. It is also possible that clients who first receive several sessions of CPT may then feel better prepared for PE. Despite Amanda’s promising results as well as results from other studies that have utilized integrative approaches, additional research must be conducted before making definitive conclusions about the effectiveness of these treatments. Future research should also attempt to identify the active ingredients in integrative treatments. However, this may prove difficult as trauma-focused treatments can share common components. For example, cognitive processing and relaxation training play important roles in PE.

12 Recommendations to Clinicians and Students

Although it is common for clinicians to be reluctant to take on more complicated cases of PTSD, Amanda’s case illustrates that even if a case is complicated and suicidality concerns arise mid-treatment, trauma-focused treatment can be modified and can successfully proceed. Therefore, it is important that as a field, we continue to explore how to most effectively address these concerns and create empirically supported guidelines for clinicians on the frontline.

Amanda’s case also illustrates that flexible approaches to treatment that incorporate other treatment modalities can be well-tolerated and beneficial to the client’s progress in treatment. Therefore, it is recommended that clinicians and students seek out training in several treatment modalities so they can integrate other techniques or change treatment modalities if necessary. Most importantly, although Amanda experienced some difficult moments in treatment in which she did not want to continue, and had increases in symptomatology and suicidal thoughts, she ultimately experienced significant improvements in PTSD, depression, and anxiety symptoms and successfully completed treatment. Amanda serves as a great reminder that although trauma treatments such as PE can be intense, they are effective.