Clinician’s Corner: Intensively Delivered PTSD Treatment: ‎ Moving Beyond the One-Session-Per-Week Model for Trauma-Focused Therapy – Michelle L. Miller, PhD; Merdijana Kovacevic, PhD; and Philip Held, PhD

Cognitive behavioral therapies (CBTs) have been used successfully over several decades to address psychiatric sequelae following trauma exposure, including one of the most common disorders, posttraumatic stress disorder (PTSD). Several trauma-focused CBTs, including cognitive processing therapy (CPT), prolonged exposure (PE) and narrative exposure therapy (NET), have been demonstrated to be effective and are recommended as first-line interventions for the treatment of PTSD (for review, see VA/DOD Clinical Practice Guidelines, 2017). One of the benefits of CBTs for PTSD is that these therapies are manualized and designed to provide a routine session structure. Manualized CBTs are typically delivered for either a specified amount of time (e.g., 10-12 sessions) or until treatment goals have been reached. Although the session length may vary between 50-90 minutes, the one-session-per-week model for trauma-focused therapy has become the norm in general outpatient practice.

Regular attendance and treatment dropout are significant problems with CBTs for PTSD and create a barrier to receiving an adequate dose of the interventions (e.g., Gutner, Gallagher, et al., 2016). Barriers to treatment attendance and completion can also include treatment cost, lack of access to transportation and/or child care, and stigma, among many others. Elements of PTSD itself, such as the tendency to avoid trauma-related internal and external stimuli, may also affect session attendance and treatment completion. When oft-avoided stimuli are discussed in therapy or exposure sessions commence, dropout may be more likely. Studies have suggested that dropout is most likely to occur by mid-treatment (Gutner, Suvak, et al., 2016). One of the biggest consequences of irregular attendance or dropout mid-treatment may be that patients do not get a minimally adequate dose and therefore will not have developed strong enough skills to effectively address their PTSD. There is a need for more effective ways to deliver evidence-based PTSD psychotherapies to increase treatment completion and reduce the impact of common barriers, especially avoidance.

One promising avenue to address high dropout rates is to intensify PTSD treatments by increasing the session frequency from once per week to multiple times per week or even multiple times per day. Intensive PTSD treatments have generally been delivered in two distinct formats: 1) as part of intensive treatment programs where daily evidence-based PTSD treatments are combined with adjunctive services, such as wellness and psychoeducation, and 2) as stand-alone interventions where the evidence-based PTSD treatment is delivered daily without any additional interventions or substantial modifications of the original treatment protocol. Delivering evidence-based PTSD treatments intensively has shown great promise in addressing issues surrounding treatment dropout. Reviews have suggested that intensive PTSD treatment completion rates are generally around or greater than 90% (e.g., Held et al., 2019). Our research has demonstrated that intensive treatments are feasible and generally well-liked by patients (Held, Klassen et al., 2020). Intensive treatment delivery allows patients to focus solely on trauma processing, rather than having to also address stressors from other aspects of their lives. Patients are also able to develop strong skills due to the more frequent repetition of skill building. Participation in intensive PTSD treatments has been shown to result in large PTSD and depression symptom reductions in a matter of days, as opposed to months for treatments delivered on a weekly basis. For example, we have shown that participation in a three-week, CPT-based intensive PTSD treatment program was associated with large reductions in PTSD symptom severity from pre- to post-treatment (d = 1.53), and that patients were able to maintain gains for at least one year following treatment completion (Held, Zalta et al., 2020). Similarly, large symptom reductions have been observed for PE-based intensive PTSD treatment programs and even shorter intensive PTSD treatments delivered over the course of a single week (Ehlers et al., 2014; Foa et al., 2018).

It is often assumed that intensive PTSD treatments are only effective for individuals without psychiatric comorbidities. Mounting research is effectively challenging this assumption. Individuals who participate in intensive PTSD treatments generally present with moderate to severe PTSD and have a number of clinical comorbidities (Harvey et al., 2017). Moreover, baseline clinical characteristics (e.g., depression symptom severity) have been shown to not negatively impact treatment outcomes (e.g., Brown et al., 2019). In fact, our research has shown that individuals who reported hazardous alcohol use at the start of intensive PTSD treatment experienced comparable symptom reductions to those who did not endorse hazardous alcohol use (Held et al., 2020). Intensive PTSD treatments may also be ideal to reduce some of these comorbidities. For example, research has demonstrated that PTSD symptom reduction in intensive PTSD treatments predicts subsequent reductions in suicidal ideation (Post et al, 2020). In summary, intensive PTSD treatments have been associated with a substantial reduction in PTSD symptoms and commonly associated comorbidities (e.g., alcohol use, suicidality). Thus, in addition to improving issues associated with dropout in traditional delivery formats, rapidly reducing PTSD symptoms may also have a significant effect on improving long-term health outcomes. 

Although these preliminary results are extremely promising, additional systematic research on intensive PTSD treatment is needed. To date, no published research has directly compared intensive and traditional treatment delivery formats, although such studies are currently underway. Another unknown is the optimal dose for intensive treatment. Studies have shown daily and twice-daily PTSD treatment to be effective at reducing PTSD symptoms. Could three or four sessions per day be even more effective? It has yet to be determined when intensifying treatment loses its effectiveness or even becomes counterproductive. In general practice, most evidence-based treatments are delivered using a flexible dose and individuals are generally treated until treatment goals have been reached. Yet, most intensive treatments to date are only offered for a predetermined length (e.g., one to three weeks). It will be important to determine whether extending the length of intensive treatments when needed can help further improve outcomes. Overall, it has yet to be determined which factors make an individual an optimal candidate for either delivery format. While there may be particular clinical or circumstantial factors that would favor one delivery format over another, treatment preferences cannot be ignored in research on intensive PTSD treatments. Some individuals may prefer the idea of dramatically reducing symptoms over the course of a short but intense time period, while others with long treatment histories may be too familiar with weekly therapy for the intensive format to be appealing. Similar familiarity and preference may also exist among providers and influence the treatment offered.

An additional consideration for intensive delivery of PTSD treatments is aftercare post-treatment. As is the case with weekly evidence-based PTSD treatments, most individuals continue to experience residual PTSD or depression symptoms after they complete treatment, even if they no longer meet criteria for PTSD. Most commonly, individuals report residual symptoms within the hyperarousal cluster of PTSD (Larsen et al., 2019). Residual symptoms may still require intervention, especially if symptoms continue to interfere with functioning. Additional research is needed to determine what type of aftercare is most beneficial and how to tailor aftercare plans to specific patient needs that may remain following intensive PTSD treatment.

To date, intensive PTSD treatments have been primarily used in specialty PTSD clinics and there are a number of challenges to address before intensive PTSD treatments can reach the mainstream. Current payment models do not generally support the delivery of multiple individual sessions per day, making it challenging for practitioners in private practice to receive reimbursement. It is also unclear how intensive PTSD treatments fit with general outpatient practice, as scheduling requirements for intensive treatments may not be easily adopted by providers. Thus, the next frontier of research on intensive PTSD treatments will need to involve exploring if and how this delivery format can be implemented in general practice settings. It will be critical to identify potential implementation barriers at the organizational, provider and patient levels.

Despite these challenges, intensive treatment delivery holds great promise. It may be time to rethink how we deliver treatment for PTSD and move away from the one-session-per-week model. Increasing the sessions’ frequency has the potential to help more individuals get better, quicker, and may thus positively impact long-term health outcomes.

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