Is Phase-Based Treatment Needed for PTSD?

Although there is no controlled research supporting the idea that patients need to be prepared to start evidenced-based treatments (EBTs) like cognitive processing therapy (CPT) or prolonged exposure (PE), there is a widespread belief among therapists that a preparatory phase may be beneficial or even necessary. Phase-oriented approaches consist of at least two parts, one phase in which some type of stabilization is provided, particularly with skills to increase emotional regulation or coping skills, followed by a trauma-focused treatment. A meta-analysis of phase-based programs found considerable improvements over time but most studies examined did not have control conditions or used only waitlists/supportive counseling and not direct comparisons to EBTs only.

Therapists' beliefs in the readiness of patients may affect whether they are offered treatment at all. One VA study of readiness for a residential program was based on mental health directors and providers based on subjective judgments of stability, readiness to change, and skills to manage distress. However, they admitted difficulties predicting who is actually ready for treatment or for which kind of treatment.

A study of community therapists’ attitudes toward learning CPT found that many therapists thought that phase-based treatments were necessary. Although beliefs changed with case consultation, those who maintained their preexisting beliefs were less likely to complete training.

On the other hand, there is abundant evidence that EBTs like CPT or PE, without any introductory phase, are effective in reducing PTSD symptoms, even among those with comorbidities such as depression, dissociation, suicidal ideation, substance abuse, and personality disorders. Adding a preliminary stage to treatment may, in fact, delay treatment or result in treatment dropout. Some examples follow:

De Jongh et al. (2016), along with 20 other authors, reviewed treatment guidelines for Complex PTSD (CPTSD). The focus was on the need for a stabilization phase before trauma-focused treatment. After a complete review of the available treatment research, they determined that in studies with stabilization only, the dropout rate was about 50 percent and did not differ in PTSD or affect regulation compared to waitlist conditions.

There was no research comparing phase-based treatment directly to trauma-focused treatment only.

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The available research on trauma-focused therapy with CPTSD or child sexual abuse without a stabilization phase showed significant improvements and no adverse effects. De Jongh concluded that treatment guidelines for CPTSD that recommend a stabilization phase may risk patients being denied or delayed from effective evidence-based treatments.

In a study of adolescents in Germany with a child sexual abuse history, Rosner et al. (2019) conducted a phase-based treatment including commitment and emotion management followed by cognitive processing therapy (CPT). The CPT was conducted intensively over four weeks. Although there was a slight improvement in symptoms during the first phase, there were large reductions in symptoms following CPT. This included significant effects on PTSD, depression, borderline symptoms, behavior problems, and dissociation by the three-month follow-up.

Dedert et al. (2021) focused on the widespread use of phase-based approaches for veterans using actual VA clinic data from 778 veterans who sought treatment for PTSD. Clinic directors have reported adopting preparatory groups to increase readiness for evidence-based treatments (EBTs), typically CPT or prolonged exposure (PE), to improve coping skills and reduce no-shows. These preparatory groups included psychoeducation about PTSD symptoms and relaxation skills, increasing positive behaviors to reduce PTSD symptoms, along with cognitive restructuring and anger management.

What Dedert et al. found was contrary to those expectations. Standard procedures for clinicians were to describe treatment options, recommending CPT or PE as first-line treatments with the most evidence (and later in the study period, EMDR), but suggested that any patients who had reservations about treatment be first enrolled in a ten-week preparatory treatment. A total of 391 veterans initiated preparatory treatment. Only 24 percent subsequently initiated one of the EBTs. A total of 530 veterans initiated an EBT without a preparatory group. Preparatory groups resulted in small changes in symptoms of PTSD and depression. When an EBT followed the preparatory group, there were also small decreases in symptoms. However, when EBT was started first, the treatment resulted in moderate to large decreases in PTSD and depression symptoms. Dedert's findings indicated that the preparatory groups did not increase participation in an EBT and that direct entry into an EBT worked better than treatment following the preparatory group.

One question to ask, given the lack of evidence that a preparatory phase is either necessary or sufficient, is why phase-based treatments are so popular.

One possibility is a lack of knowledge about these findings. Another is that therapists have their own fears about doing EBTs. In an article on therapists' "stuck points" (inaccurate beliefs) prior to training in CPT, the second most common (of 37 items) was “Clients need preparatory treatment before they are ready to deal with their trauma.” Higher levels of therapist stuck points and less reduction in stuck points during training resulted in a lower likelihood of completing training requirements and less use of CPT 12 months later.

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Perhaps more focus should be on training therapists so that patients are not denied treatments that work.