PTSD and trauma: New APA guidelines highlight evidence-based treatments

A trio of new APA guidelines on treating posttraumatic stress disorder (PTSD) and complex trauma aim to help psychologists broaden their practice with adults who have experienced traumatic events and guide clinicians on how to personalize treatments while still relying on evidence-based practice.

The latest Clinical Practice Guideline for the Treatment of PTSD in Adults was approved by the APA Council in February, joining the professional practice Guidelines for Working with Adults with Complex Trauma Histories (PDF, 428KB)opens in new window and Guidelines on Key Considerations for Working With Adults With PTSD and Traumatic Stress Disorders (PDF, 731KB)opens in new window, both approved in August 2024. The latter two guidelines are the first of their kind, while the Clinical Practice Guideline for the Treatment of PTSD in Adults is an update of the 2017 APA guideline on the same subject.

All three guidelines expand on the treatment of PTSD and trauma. While the 2017 guideline worked from only one systematic review of research, the updated guideline now draws from 15 systematic reviews of interventions and takes into account a broader array of outcomes than PTSD symptoms alone. Meanwhile, the new professional practice guidelines focus on broader competencies around working with persons who have been exposed to trauma. These guidelines do not recommend certain interventions but provide frameworks for clinicians to think about training, professional development, and the context in which they might meet traumatized persons. For example, is the trauma a one-time, life-threatening accident, or an ongoing personal trauma, as in domestic violence or childhood sexual abuse? Might the person be involved with the legal system, possibly exacerbating their problems? Are there cultural considerations or generational patterns of trauma at play?

The result is three guideline documents that complement each other, coming at a time when psychologists are more attuned than ever to the ubiquity of traumatic experiences.

“The world has been going through chronic trauma since 2020,” said Robin McLeod, PhD, senior director for strategic relations and leadership on the Practice team at APA. “It’s not only the pandemic but national and world conflicts that have led to political disruption, war, and displacement. We know that chronic trauma has a huge impact on long-term physical health and that it is our young people who are most impacted. Psychologists, recognizing this, are honing their ability to integrate an understanding of trauma into their work with everyone. These guidelines provide clinical and professional support for this integration.”

The newly approved clinical practice guideline focuses on interventions for PTSD. Compared with the previous guideline, the new document pays more attention to complex presentations of PTSD. And while the critical outcomes the guideline development panel looked at involved the reduction in PTSD symptoms such as intrusive, distressing memories of the trauma, outbursts of anger, or sleep disturbances, they also considered the impact of interventions on other important outcomes, including substance use, affect dysregulation, suicidal ideation, and dissociation.

“There was more emphasis on including outcomes that address complexity,” said Lori Zoellner, PhD, a professor of psychology at the University of Washington who chaired the guideline panel. “We paid attention to clinically meaningful change, quality of life, and functioning. So we purposely took a broad approach.”

Drawing from 15 systematic reviews, the guideline developers found three interventions that reached the highest standard for evidence. Psychotherapy over pharmacotherapy defines the recommended interventions. Adults with PTSD can be treated with cognitive processing therapy (a cognitive behavioral therapy-based program that walks patients through processing trauma by examining trauma-related beliefs), prolonged exposure therapy (an approach that guides patients through facing trauma-related reminders and memories), and trauma-focused cognitive behavioral therapy (a combination that often includes psychoeducation, relaxation, cognitive restructuring, and exposure therapy components).

“These interventions were rated as recommended because there are many high-quality studies that show large effects,” Zoellner said. “They’re done by independent research groups, and they have a consistent pattern of findings across both the critical outcomes and the important outcomes, and the quality of science is generally rated as either moderate or high. They have good science behind them.”

The second tier of interventions is also viewed as effective, with the guideline likewise suggesting the use of these interventions. The research base for these second-tier interventions is not as strong: The studies may not be as high in quality or showed more variability for important outcomes. Among the suggested interventions were eye movement desensitization and reprocessing (EMDR), which guides patients to revisit traumatic memories while engaging in bilateral movements with their eyes or hands; cognitive therapy, which involves reevaluating trauma-related beliefs; and narrative exposure therapy, which aims to help patients build a narrative to contextualize their trauma. The guideline also suggests offering selective serotonin reuptake inhibitors or serotonin and norepinephrine reuptake inhibitors.

The panel also delved into the evidence for many emerging treatments that have become popular, particularly MDMA-assisted therapy and ketamine for PTSD. They found that, so far, the evidence base is simply insufficient to recommend for or against these treatments. Many of the studies that have been done are small or at risk of bias, or the treatment protocols are unclear. Other interventions and comparative effectiveness studies were also reviewed, and the evidence base for those is growing, Zoellner said. “We’re awaiting better clinical trials,” she added.

The guideline also urges clinicians to consider barriers to treatment and ways to overcome those barriers, and to share decision-making with patients, considering factors like the setting where the treatment will be delivered and the time and resources the patient must devote to therapy. The guideline also outlines some key factors that effective therapies seem to share, such as teaching patients to manage negative emotions about themselves.

“The point is to help these people let go of some of their symptoms so that [they] can get back to a quality of life and a life they want to live,” said Priscilla Schulz, LCSW, a clinical social worker in Seattle and vice chair of the guideline committee.

Meanwhile, the Guidelines on Key Considerations for Working With Adults With PTSD and Traumatic Stress Disorders gives professionals a broader base for approaching practice with people who have experienced trauma.

“Our job was not to approve any specific type of therapy,” said guideline panel chair Lenore Walker, EdD, ABPP, a forensic psychologist and professor emeritus at Nova Southeastern University in Florida, “but rather to address how the general practitioner who is going to work with somebody who has faced trauma should behave—the guidelines are to help them in making all kinds of choices.”

The guideline starts by urging psychologists to take a cross-disciplinary, culturally responsive approach to assessing and treating trauma, keeping up with the rapidly evolving research in this area. Patients may come into the psychologist’s office with preexisting notions of what trauma is and how to treat it, possibly gleaned from social media and self-help books. Some of that information may be accurate, while some is not, and psychologists may need to help patients sift the good from the bad. Most clinical training programs are light on education around trauma, Walker said, but there are numerous continuing-education options available. Such programs can help clinicians understand the biopsychosocial, cultural, and intersectional complexities of trauma, as can seeking consultation from more experienced mentors and colleagues. Professional peer-to-peer support can be particularly important for preventing secondary trauma and burnout, the guideline notes. Even steps such as taking more breaks on days when seeing trauma survivors can help.

Given the regulations around treating victims of violence—such as mandatory reporting laws for child abuse—a large portion of the guideline focuses on legal frameworks. Laws vary by state, and psychologists are encouraged to understand their legal responsibilities around what must be reported and how to assess whether a patient might be a threat to themselves or to others. Psychologists may also find themselves working with patients who are entangled in the legal system, Walker said. Practitioners may want to familiarize themselves with the court system to be able to discuss the impact of this involvement on the patient’s mental health and day-to-day life and logistics. They may also want to make choices about treatment with legal proceedings in mind; for example, choosing to treat trauma with hypnosis or exposure therapy might alter the patient’s memory of the traumatic event, which might affect their ability to pursue a legal case.

The guideline encourages psychologists to consider how patients from different cultures might experience and express trauma. A holistic assessment strategy, pulling from multiple sources of information, may help psychologists consider a patient’s life circumstances and overall health.

The guideline also encourages psychologists to adhere to the principles of trauma-informed care. Trauma-informed care recognizes that most people with behavioral health disorders have some experience of trauma in their lives. This approach encourages screening patients for trauma history and responding to trauma with a mixture of compassion and respect. People who have experienced trauma already have their own forms of resilience and coping skills, and clinicians can build their patients’ confidence and trust by acknowledging what has worked for them.

The guideline outlines some specific types of trauma that might bring a person to a therapist, such as sexual harassment, immigrating because of war or persecution, or racism and intergenerational discrimination. Psychologists can also consider the impact of systemic racism and generational trauma on their patients, as well as the impact of barriers to getting treatment and care. For example, telehealth might be a good option for a veteran whose combat-related trauma triggers anxiety, hypervigilance, or aggression when driving, or for a person who has a history of medical trauma and thus experiences anxiety in a clinic setting.

The guideline underscores that “each trauma is different, and each person is different,” Walker said.

The other professional practice guideline, jointly produced with the International Society for the Study of Trauma and Dissociation, focuses on adults with complex trauma histories. The complexity of trauma is along a continuum, but generally someone with complex trauma is likely to have experienced multiple traumatic events or to have been victimized repeatedly, typically in an interpersonal, intentional way, such as in an emotionally or physically abusive relationship. Often, trauma that happens earlier in development, or in multiple developmental phases across the life span, presents with more complex sequelae.

These factors are included in the diagnosis of complex PTSD, which is included in the 11th edition of the International Classification of Diseases (ICD-11) of the World Health Organization. As in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) definition of PTSD, a diagnosis of complex PTSD requires exposure to or experiencing events or circumstances that overwhelm the ability to cope, including those involving direct interpersonal and emotional threats. These result in the development of symptoms that meet the original three criteria of PTSD (reexperiencing the trauma in the present, numbing and shutting out reminders of the trauma, and physiological hyperarousal and hypervigilance). But three additional criteria under the heading “disturbances in self-regulation” are also required. These are difficulties in identifying and regulating emotions, negative self-concept, and low self-worth, and problems maintaining or forming relationships.

The DSM-5 does not have a separate diagnosis called complex PTSD, but the developers of the DSM-5 and the developers of the ICD-11 worked together to make the DSM-5 PTSD criteria and ICD-11 complex PTSD criteria somewhat similar. For example, the DSM-5 PTSD diagnosis includes components such as estrangement from others and negative views of self. Clinicians and researchers debate whether these conditions are fully different.

Whether or not a person meets the diagnostic criteria for complex PTSD, a complex trauma history can lead to more complicated symptoms, said Christine Courtois, PhD, ABPP, a counseling psychologist and consultant on trauma psychology and treatment who chaired the complex trauma guideline development panel. Often, trauma that happens earlier in development, or in multiple developmental phases across the life span, presents with more complex symptoms. For example, it may lead to the development of dissociation as a defense and coping mechanism.

“When you’re treating complex PTSD, you have more things to treat,” Courtois said. “Because many of these individuals didn’t get what they needed in childhood to help them develop themselves in a positive sense and to develop emotional regulation skills, that becomes part of the therapy.”

To assist clinicians in treating these patients, the guideline uses the acronym history. “H” stands for taking a humanistic approach, acknowledging that complex trauma patients may have experienced inhumane treatment at the hands of those they should have been able to trust, including authority figures and professionals (recognized as betrayal or relational trauma). Psychologists can redress these betrayals not only by choosing interventions to undo past harms but by helping patients become and feel safe in the present day, fostering their personal agency, and reinforcing their sense of self-efficacy.

“I” stands for integrative solutions, encouraging psychologists to take a personalized, patient-centered approach to treatment. This might mean, for example, augmenting traditional evidence-based therapies with evidence-informed, nontraditional therapies such as mindfulness or yoga. Or it might mean helping a patient tackle present-day problems in relationships or daily functioning before digging into the root of the trauma.

“S,” for “sequence,” also addresses the importance of assessing a patient’s readiness before beginning an intervention aimed at addressing the trauma history. “It’s important to have a base of safety and to teach some stabilization skills,” Courtois said.

The “T” in history stands for “timeline,” emphasizing the importance of taking a developmental view. This can include considering both when the trauma occurred and the person’s current stage of development. For example, a high school student may present different symptoms than a person near the end of life, Courtois said. As older adults experience health problems or cognitive decline, they may find past traumas resurfacing, including traumas they have never told anyone about.

Whatever the presentation, the guideline urges a transdiagnostic view of symptoms and outcomes. Therefore, the “O” of the guideline acronym stands for “outcomes” and encourages psychologists to assess all problems of a patient and tailor treatment according to the individual’s unique needs. Consistent with a patient-centered approach, there is no “one size fits all,” said Paul Frewen, PhD, a clinical psychologist at Western University in Ontario who cochaired the development of the complex trauma guideline. “We need this flexibility to meet the person where they are,” Frewen said.

All this work is predicated on the therapeutic relationship (the “R” of the acronym), which emphasizes the importance of the therapeutic alliance in predicting outcomes. It is important to be responsive, reliable, trustworthy, and consistent, Courtois said, in order to provide the individual with a different relational experience that can become a template for the patient’s outside relationships.

Finally, the guideline encourages psychologists to help patients find the “why” (or the “Y” in the acronym) for what happened to them. Exploring these existential questions can help people reappraise the trauma and understand that they were not to blame.

Taken together, these three guidelines should give psychologists a strong sense of the evidence base for treatments as well as the complexity of treating individuals with their own histories, goals, and symptoms.

“While trauma makes a person feel little and small, squashed, tiny,” Frewen said, “through therapy they’re able to become more fully themselves, and open up and broaden and build.”