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Evidence of Absence: Proposals for Improving Treatment of Combat-Related PTSD

How can Div. 19 more effectively serve those suffering from combat-related PTSD?

By Jared W. Bollinger

This article focuses on Div. 19's Strategic Objective: to advance the science of military psychology that serves to stimulate, promote and support military psychology research.

Have we, as a military psychology community, put the "cart in front of the horse" in determining which treatments are best for combat-related posttraumatic stress disorder (PTSD)? I would like readers to consider the following questions while reading this article:

  • Are we truly implementing evidence-based practice that balances research evidence, patient preferences and clinical expertise (Levant, 2005) to treat combat-related PTSD?
  • How involved are military psychologists in treatment development research for combat-related PTSD?
  • Do recommended treatments sufficiently emphasize common factors in psychotherapy?
  • How was combat-related PTSD treated in previous eras? And what knowledge have we learned and kept from our predecessors?


Psychotherapy is a mainstay of PTSD treatment. In recent years, there has been rapid implementation of prolonged exposure (PE) and cognitive processing therapy (CPT) for combat-related PTSD. This is significant, because over 2.5 million military members have deployed to combat zones since the 9/11 terrorist attacks (Institute of Medicine, 2013). The treatments that military psychologists use have an enormous effect on patients' symptoms and the acceptability of mental health treatment.

What is the evidence for PE and CPT in treating combat- related PTSD? And are these treatments well tolerated?

The efficacy of PE and CPT was primarily determined from studies of civilians with PTSD. Few trials have been conducted within the Department of Veterans Affairs or the Department of Defense (DoD). In a recent review of all randomized clinical trials for combat-related PTSD, only seven of the 36 (19 percent) studies identified used a sample of active duty military members (Steenkamp, Litz, Hoge, & Marmar, 2015). Of these seven studies, only one trial tested either PE or CPT (there were, however, 12 trials testing either PE or CPT using veteran samples). Of note, in the lone trial of CPT in active duty members, 27 percent of the CPT group dropped out of treatment (in comparison to 13 percent in the control condition receiving present-centered therapy; Resick et al., 2015). Despite the relative lack of data in active duty samples, PE and CPT are recommended as first line treatments for combat-related PTSD according to multiple clinical practice guidelines (Depart ment of Veterans Affairs & Department of Defense, The Management of Post-Traumatic Stress Working Group [VA/DoD Working Group], 2010; Institute of Medicine, 2014; World Health Organization, 2015).

Other research has suggested that patients with combat- related PTSD may not respond, tolerate or have time to complete PE or CPT. Up to 66 percent of participants in clinical trials treated with either CPT or PE retained their PTSD diagnosis after treatment in the Steenkamp et al. (2015) study. In addition, 30 to 51 percent of participants did not have a clinically significant response to these therapies in their review. PE and CPT also have high levels of participant dropout. In a large effectiveness study of PE at multiple Veterans Affairs (VA) hospitals, the dropout rate was 28 percent (Eftekhari et al., 2013). The most common reason for dropout in this study was increased distress (Eftekhari et al., 2013). The study demonstrated that veterans of the wars in Iraq and Afghanistan were more likely to drop out of treatment, which was replicated in a similar study (Mott et al., 2014). In the most recent clinical trial of PE with an active duty military sample, the dropout rate was 40 percent (Reger et al., 2016).

Proposal 1: Military Psychologists Should Participate More in PTSD Research

Military psychologists are firstline providers for treating combat-related trauma. Military psychologists often deploy alongside their patients in embedded roles and have firsthand knowledge of deployment stressors. They also care for active duty members at hospitals in theater, abroad and at home. Div. 19's members have the unique understanding of the challenges related to treatment preferences, time considerations and cultural factors with implementing psychotherapy in a military context. However, the treatments the DoD/VA recommends were first developed by civilian psychologists for civilian traumas.

It makes sense that military psychologists may not be involved in major research endeavors. This is due to busy clinical obligations, frequent relocations and other administrative requirements. Clinical psychology billets may need to incorporate more research requirements into their assignments, at least on a part-time basis. Some of these types of billets exist but could be further expanded strategically through Div. 19 leadership. Research-oriented billets may be limited to certain duty locations, based on military populations served. For example, Naval Hospitals Pendleton and Lejeune have units with high numbers of combat deployments. At these locations, one psychologist may have a designated role in researching combat-related PTSD treatment as a part of the person's billet's role.

Antonio Puente is the president of the American Psychological Association. His research has emphasized collaboration with the military to enhance the understanding of traumatic brain injury (see Puente & Francis, 2015). His model could be followed as an example of how military and academic partnerships can improve treatment research for combat-related PTSD. Academics could help write the grants and coordinate administrative requirements for testing new treatments, with military psychologists serving as clinical coordinators. Military psychologists could also be consulted during the development of treatment protocols.

Proposal 2: Emphasize Common Factors in Psychotherapy

Most of psychology's professional and continuing education emphasizes specific treatments such as PE and CPT. But what do psychologists know about what works in psychotherapy? What are the most robust findings on what drives symptom change? In one of the more influential books on PTSD treatment, “Trauma and Recovery,” Judith Herman (1997) wrote that the most important components of effective trauma treatment are developing a strong therapeutic relationship and instilling a sense of safety. But are rapidly paced, itemized therapies like PE and CPT counterproductive to these goals?

When looking at the accumulated body of psychotherapy research generated over several decades, nonspecific factors (such as therapeutic alliance) have been found to have the greatest effect on outcomes. When the prolific psychotherapy researcher Bruce Wampold evaluated several meta-analytic studies, he found nonspecific factors such as alliance, collaboration and therapist empathy to have the most robust effects on therapeutic outcomes (Wampold, 2015). Conversely, he found that specific factors in psychotherapy (e.g., exposure, cognitive restructuring) are minimally correlated with patient outcomes. Nonspecific factors ("common factors") consistently had greater effect sizes (ranging from .25 to .7) than did specific treatment factors (ranging from less than .05 to .2; Wampold, 2015).

What can be recommended from this massive body of research? Psychologists need to emphasize (and not over- look) common factors. Common factors seem to be mentioned in treatment guidelines as a side note or not ad- dressed at all. For example, in the VA/DoD treatment guidelines for PTSD (VA/DoD Working Group, 2010), the word “alliance” is mentioned six times and the word “collaboration” is mentioned just one time (and outside of any meaning for clinical care). In contrast, the term “in-vivo” is mentioned 12 times, “imaginal” 21 times and “restructuring” 30 times. The devaluation of common factors in psychotherapy may be related to graduate school training. For example, humanistic or client-centered therapists whose treatments emphasize nonspecific factors (respect, alliance, unconditional positive regard and empathy) constitute only 11 percent of clinical psychology faculty members (Norcross & Sayette, 2016).

Proposal 3: Learn From History

Combat-related PTSD is not a new clinical entity. However, it was not until 1980 that PTSD entered the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1980). Terms previously used to describe PTSD included “shell shock,” “battle fatigue,” “war neurosis” and “operational exhaustion.” Rich case studies on the treatment of combat-related PTSD have been written by clinicians of World War I, World War II, the Korean War and the Vietnam War. What has been learned from the treatment reports of the military and VA psychologists and psychiatrists from yesteryear? How did clinicians effectively treat patients before PE and CPT? From a student's perspective, this information is distant and unclear.

I propose that Div. 19 form a committee to write a formal "History of Psychotherapy Treatment for Combat- Related PTSD." This project could be of considerable scientific and clinical value. Distilling the history would ensure that valuable treatments and techniques do not become overlooked or lost. It may clarify how treatments differ in effectiveness by type of conflict (e.g., guerilla warfare in Vietnam vs. long campaigns on the Western front). With this task, one could reintroduce, refine and test new protocols.

Although the amount of combat-related PTSD research has exploded in recent years, one must not forget the work done by predecessors. Synthesizing this literature is no easy task, but various texts exist. Sources such as Kardiner's (1941) The Traumatic Neurosis of War (World War I) and Grinker and Spiegel's (1944) Brief Psychotherapy for War Neuroses (World War II) serve as powerful and well-written representations of PTSD treatment during previous conflicts. Div. 19 would also benefit by reaching out to retired military psychologists. One could conduct interviews with these psychologists on the history of the standard of care for combat-related PTSD.

Conclusion: Integrated Focus

The goal of this article was to make readers aware of the shortcomings of the current efforts in research and treatment of combat-related PTSD. The current evidence has suggested that recommended treatments are marginally effective and have high dropout rates. Military psychologists bring unique expertise to improving existing treatments. Specific recommendations include having more military psychologists involved in treatment development research. This would be accomplished through partner- ships with academia but also through more billets with research components. Existing treatments may stand to be improved by emphasizing and incorporating common factors into new treatments. Also, new psychotherapies could be rebranded and developed from treatments used during previous wars. These recommendations may help refine and improve care for combat-related PTSD.


The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Uniformed Services University of the Health Sciences, Department of the Navy, Department of Defense or the U.S. Government.

For further information, please contact Jared W. Bollinger.


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