In 1969 Paul asked “What treatment, by whom, is most effective for this individual, with that specific problem, under which set of circumstances, and how does it come about?” (Paul, 1969, p. 62). Although we have advanced significantly since Paul posed this question, we are still far from answering this question. In the beginning, research and practice attempted to tailor treatment to diagnostic classification. These studies found “modest differences between treatment methods that are largely independent of other factors influencing outcome” (Shapiro & Shapiro, 1982, p. 598). We now know that comparisons between treatment approaches yield only minor differences. For example, Cuijpers et al. (2008) conducted seven meta-analyses in which seven major types of psychological treatment for depression were examined and conclude that “There was no indication that 1 of the treatments was more or less efficacious…. This study suggests that there are no large differences in efficacy between the major psychotherapies for mild to moderate depression” (p. 909).

Tailoring treatment appropriate to diagnosis requires accuracy in our diagnostic systems. However, both major diagnostic systems (DSM and ICD) ignore etiology, intrapsychic conflicts, family and social networks, and ego strengths. This neglect may affect treatment selection. In addition, since the diagnosis is determined on the basis of the appearance of a set of symptoms from a larger possible number, heterogeneity among patients in each diagnostic category is huge. In order to diagnose PTSD employing the DSM, a patient must display one of five symptoms from criteria B, three of seven from criteria C, and two of five from criteria D—yielding 49 different manifestations of the disorder. It is not possible to tailor a treatment that will be equally effective with all 49 manifestations of the disorder. A partial solution might lie in subdividing the diagnostic category in order to make it more homogeneous, for example, into three subcategories: behavioral, cognitive, and physiological PTSD, i.e., PTSD with primarily cognitive manifestations of guilt, anger, hopelessness, etc., PTSD with primarily avoidant behavior, and PTSD with increased arousal, etc. This may aid in choosing the most appropriate therapy. For lack of a better system, this approach will be discussed later on in this chapter. However, this division may not be sufficient. It is important to examine patient characteristics which do not appear in the diagnosis, but may also influence treatment choice.

In order to choose patient characteristics, an accepted model which would guide the researcher/clinician to choose relevant patient variables is required. To date, no such accepted model exists, rendering this task unattainable. Single variable models which match treatment to patient abound, for example, on the basis of attributions, self-control, hemisphere dominance, etc. These models are somewhat helpful, but far from satisfying. Several multivariate models have been proposed as well; for example, the model developed by Beutler and Clarkin (1990) which takes into account patient, therapist, and therapy variables, as well as the evolving nature of the therapeutic process. I attempted to employ their model in a paper published in 2000 (Wallach, 2000). It was a very interesting exercise, which taught me humility. I found that the more I thought I knew and understood about the therapeutic process, the more I discovered that I still needed to learn. The model turned out to be very illuminating as a post (therapy)-mortem, but irrelevant as a guide to choosing therapeutic interventions.

PTSD is a complex disorder. It affects all aspects of the individual’s life—social, familial, marital, work, sleep, physical, affective, and more. As detailed elsewhere in this book (Echterling, Stewart, & Field, 2013), diagnosis has evolved through the years, and we are now able to make a precise diagnosis as who suffers from PTSD, and who does not, as well as length and depth of the disorder. We also are able to trace and map the neurological underpinnings, as described in other chapters of this book (Gilboa, 2013; Richter-Levin, 2013). Two main effective therapies have been developed to treat PTSD—Prolonged Exposure, developed in the mid 1980s by Edna Foa and colleagues, and described in this book (Foa, Nacasch, & Rachamim, 2013), and Cognitive Processing Therapy developed by Patricia Resick and colleagues in the 1990s and described in this book (Chard & Walter, 2013). Recently, Interpersonal Therapy has been successfully applied to PTSD as well and is described in this book (Klein Rafaeli & Markowitz, 2013). In addition, in recent years, modifications to these various therapies have been successfully employed: adding D-Cycloserine (Burton, Youngner, McCarthy, Rothbaum, & OlasovRothbaum, 2013) and using Virtual Reality (Garcia Palacios, Botella, Banos, Guillen, & Vicenta Navarro, 2013; Rizzo, 2013). Karen Seal and her group (Seal, 2013) have also attempted to locate the treatment in a general healthcare facility to reduce stigma and other barriers to therapy.