PTSD: National Center for PTSD

Present-Centered Therapy for PTSD

M. Tracie Shea, PhD

Present-Centered Therapy (PCT) is a time-limited treatment for PTSD that focuses on increasing adaptive responses to current life stressors and difficulties that are directly or indirectly related to trauma or PTSD symptoms. Findings from many randomized clinical trials (RCTs) that included PCT as an active control condition have led to PCT being recognized by Division 12 of the American Psychological Association as a research-supported psychological treatment for PTSD (1). It is also recommended as a second-line treatment in the VA/DoD clinical practice guideline (2) and given a similar ("standard") recommendation in the updated ISTSS guidelines (3).

Theoretical Model

PCT was initially developed as a nonspecific comparison condition to test the effectiveness of trauma-focused cognitive behavioral therapy (TF-CBT). The goal of PCT was to control for therapeutic elements that are present in psychotherapy more generally, to allow conclusions about the effects of the unique interventions in trauma-focused therapy. The theoretical basis for PCT is derived from the large literature on such "common factors" and their role in psychotherapy. The idea that factors that are present in different forms of psychotherapy play an important role in outcome was introduced in 1936 (4) and expanded upon by Jerome Frank (5). Examples of common factors include a supportive therapeutic relationship, a psychotherapeutic rationale that explains the patient's symptoms and the procedures of therapy for relieving them, the experience of talking about problems in a safe environment, and the creation of positive expectations and hope. PCT was developed to embed such common factors within a supportive, problem-solving treatment framework addressing PTSD symptoms and associated features.

Interpersonal disconnection and helplessness are 2 important themes associated with the after-effects of trauma and the symptoms of PTSD (6,7). PCT addresses interpersonal disconnection through interventions designed to enhance the development of a positive therapeutic relationship, by encouraging connection with others, and by providing the opportunity for patients to explore interpersonal difficulties in therapy sessions. PCT, like all forms of therapy, is designed to enhance a sense of mastery. This is facilitated by psychoeducation about PTSD symptoms and an emphasis on identifying how these symptoms may influence and/or interact with current emotions and difficulties. PCT also encourages problem-solving, helping the patient to articulate the nature of the problem and to think about ways of responding. As part of this process, PCT relies heavily on engaging the patient's strengths and prior experiences.

Session Content

There are manuals for PCT in group and individual formats. As a result of trying to match the amount of therapy in different RCTs, the number and length of PCT sessions studied has varied. The number of sessions has ranged from 12 to 32 for the group format and 10 to 12 for individually delivered PCT; the length of sessions has varied from 60 to 90 minutes. The first 2 sessions in both formats provide an overview and rationale for PCT and psychoeducation about PTSD symptoms and other common responses to trauma, presented in an interactive format. Subsequent sessions are less structured, focusing largely on topics chosen by patients, who (in the individual format of PCT) are encouraged to use a daily diary to record issues and problems of concern throughout the week. The final session is devoted to reviewing progress and processing termination. Therapist interventions include close listening, reflection, providing validation and support, encouraging expression of feelings, and encouraging problem-solving to enhance coping.

Overall and Relative Effectiveness

PCT was developed as a comparison condition within the context of 2 large multi-site VA clinical trials. The first (8) compared PCT using a group format to a trauma-focused group therapy; the second compared individual PCT to Prolonged Exposure (PE) therapy (9). Independently, a different version of Present-Centered Therapy was developed to serve as a comparison condition in an RCT of cognitive behavioral therapy (CBT) for PTSD in adult female survivors of childhood sexual abuse (10). Like the version developed for the VA multi-site RCT, this version includes psychoeducation about trauma and PTSD, focuses on current life difficulties, and excludes cognitive behavioral interventions. Differences include the use of a theoretical framework specific to childhood sexual abuse for the psychoeducational component, a more formalized and systematic emphasis on problem-solving, and assigned homework to write about problem-solving efforts in a journal reviewed with the therapist. This version of PCT has been used in one additional study (11); all other studies have used the VA (8,9) versions.

There are now 20 RCTs where one or more of the treatment arms included PCT, many with relatively large samples (12). A Cochrane review meta-analysis of the effectiveness of PCT (13) compared PCT to inactive controls and to trauma-focused cognitive behavioral therapies (TF-CBT), considered the most effective treatments for PTSD (3). Compared to inactive controls, PCT (individual format) showed significantly greater reduction in PTSD severity and a larger decrease in PTSD diagnosis. Eleven studies were included in a non-inferiority analysis to determine if PCT resulted in similar reductions in PTSD symptoms assessed by the Clinician-Administered PTSD Scale (CAPS) compared to TF-CBT. Findings for PTSD severity at post-treatment did not support non-inferiority (i.e., there was a meaningful difference between PCT and TF-CBT). However, differences between the treatment approaches decreased at 6- and 12-month follow-up assessments. There were no meaningful differences on self-report measures of PTSD or on symptoms of depression at post-treatment, and PCT had significantly lower dropout rates. Thus, while TF-CBT approaches are associated with better outcome for PTSD severity at the end of treatment, the evidence shows that PCT is an effective alternative that may be particularly relevant when TF-CBT is not available or not desired.

PCT in Clinical Practice Guidelines

PCT is recommended as a second-line treatment for PTSD in the 2023 Department of Veterans Affairs/Department of Defense (VA/DoD) Clinical Practice Guideline for PTSD (2), has a standard recommendation (second-line) by the International Society for the Study of Traumatic Stress (ISTSS; 3), and a conditional for (second-line) recommendation in the Australian guideline (14). PCT is not mentioned in the American Psychological Association (15) or the U.K. National Institute of Healthcare Excellence (16).

Research With Military Personnel and Veterans

Ten of the 11 studies comparing PCT with TF-CBT included in the meta-analysis (13) were conducted with active-duty military (17,18) or Veteran (8,9,19-24) samples. Thus, the cumulative evidence shows that for active-duty personnel and Veterans combined, PCT has lower dropout rates, but is less effective than TF-CBT in reducing PTSD severity at post-treatment. In a more recent analysis (25) including just the active-duty military samples (17,18) TF-CBT did not show more improvement in PTSD severity than PCT.

Research With Comorbidities and Special Populations

Not much evidence is available regarding the effectiveness of PCT for comorbid conditions. Findings from the Cochrane meta-analysis (13) showed that PCT results in similar improvement in depression symptoms compared to TF-CBT. PCT appears to be as effective as PE in female Veterans with the dissociative PTSD subtype (26). As noted, most research on PCT has been conducted in Veteran samples, but other populations studied have shown positive effects for PCT. In a sample of adults with childhood sexual trauma, PCT was superior to a wait-list control and did not differ from CBT with exposure and cognitive restructuring (10). Similarly, PCT was superior to a wait-list control, and did not differ from a CBT without trauma-focused treatment in mothers with a history of abuse and incarceration (11). A recent study of older adults with histories of persecution and political and domestic violence (27) showed significantly more improvement in PTSD symptom severity in PCT than in Narrative exposure therapy.

Research Across Diverse Populations

More research to understand the effectiveness of PCT taking into account patient race/ethnicity, gender, sexual orientation and other social factors associated with health disparity is needed.

PCT in Group Format

Four studies (8,17,20,22) have compared a group version of PCT with a TF-CBT using a group format. Resick et al. (17) found greater decreases in self-reported (although not clinician-rated) PTSD with Cognitive Processing Therapy (CPT) group compared to PCT group in active-duty military service members. The other studies (all Veteran samples) did not find significant differences between the TF-CBT and PCT group treatments in reducing PTSD symptoms (8,20,22). The Veteran studies are consistent with findings more broadly, that while PTSD group treatment is better than no treatment, no specific manualized trauma-focused (or non-trauma focused) group therapy for PTSD has been shown to be superior to active controls (28). In general, given the low quality of evidence for group therapy, and that the limited findings that do exist suggest that group therapy for PTSD is not as effective as individual therapy, group therapy is not recommended as a first-line treatment by the VA/DoD clinical practice guideline for PTSD. Manualized group therapy is, however, recommended over no treatment. There have been no direct comparisons between PCT delivered in group versus individual format.

References

1. Division 12 of the American Psychological Association. (2016). Present-Centered Therapy for posttraumatic stress disorder. https://www.div12.org/PsychologicalTreatments/disorders/ptsd_main.php
2. Departments of Veterans Affairs and Defense (VA/DoD). (2023). VA/DoD clinical practice guideline for the management of posttraumatic stress disorder and acute stress disorder. Author. Retrieved from: https://www.healthquality.va.gov/guidelines/MH/ptsd/
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