This is the fourth in a series of guides to individualized evidence based treatment edited by Jacqueline B. Pearsons. The authors' extensive experience in the treatment of Post Traumatic Stress Disorder (PTSD) is well demonstrated in this book. Zayfert and Black Becker aim to find common ground between two schools of thought on the usefulness of CBT for PTSD in clinical practice. One suggests that evidence based interventions such as CBT should be the first line approach when treating PTSD; the other, that patients with PTSD seen in clinical practice are different from those in research trials. From this perspective it is argued that manualized treatments like CBT limit a therapist's creativity and flexibility and may not be the best approach for complicated PTSD patients. The authors' goal is to demonstrate how CBT can be implemented in a flexible manner, allowing the varying and at times complicated needs of traumatized patients to be addressed. I believe they have achieved this goal admirably in a well structured and easy to read book. It succeeds in clearly outlining how to use a case formulation approach to provide CBT for PTSD patients on an individual case by case basis.

The first two chapters review the background the authors believe is needed to use cognitive behavioural therapy to assess and treat PTSD. The first chapter provides an overview of CBT and its empirical foundations. It then looks at the elements of CBT for PTSD and provides a brief summary of research on CBT for PTSD. Clinicians who use EMDR may not be happy with the authors' stance (they don't use it), but their rationale for this raises valid points. This chapter would have benefited from comment on other recent developments such as the metacognitive therapy approach devised by Adrian Wells. Chapter 2 gives a general overview of the cognitive behavioural conceptualization of PTSD and then focuses on the critical components. In particular, it covers why exposure and cognitive restructuring are key treatment techniques. In chapter 3, assessment and the case formulation approach to PTSD are described. The authors illustrate how to use the case formulation approach to identify appropriate interventions and tailor them to suit the individual needs of patients, particularly those with multiple and complex problems. How to conduct a comprehensive assessment of patients is discussed first, then how to integrate an individualized analysis of a patient's difficulties with the “nomothetic” or general cognitive behavioural formulation approach to PTSD.

The following chapters (4–10) describe in detail how the core components of CBT are woven into an individualized treatment programme for patients with a trauma history. Chapter 4 presents the challenges therapists face when undertaking CBT for PTSD. Issues covered include: establishing a trust with patients, therapists discomfort about increasing a patient's arousal and distress during exposure, determining a patient's readiness to start exposure, when to sequence exposure and cognitive restructuring techniques, and practical concerns or life problems that may be potential barriers to treatment. Chapter 5 covers psychoeducation about reactions to traumatic experiences, orientation of patients to CBT, and how to develop a rationale for the use of exposure and cognitive restructuring techniques. Chapter 6 focuses on the use of exposure therapy in treatment. The authors explain what patients learn during both imaginal and in vivo exposure tasks and then how to implement in vivo exposure. Difficulties that may arise in treatment when using this technique and how to deal with them are also covered. The practicalities of preparing for and implementing imaginal exposure are outlined in chapter 7. A section on troubleshooting problems that may arise during the process is also included here. Issues covered include: patients being doubtful that they can do exposure tasks, dealing with dissociating and numbing reactions, reluctance to do exposure or exposure homework, and unusual reactions, such as sexual arousal during exposure. Strategies clinicians can use to titrate anxiety during imaginal exposure to facilitate engagement and habituation are also outlined.

Chapter 8 focuses on using cognitive restructuring to help patients change the meaning of the traumatic events they have experienced by identifying and changing unhelpful beliefs they have developed. Basic strategies for identifying and restructuring common unhelpful PTSD thoughts are well presented. Although the use of behavioural experiments is briefly mentioned, I believe the book would have benefited from a more in depth discussion of how they can be used to test and challenge negative beliefs. Chapter 9 provides an overview of “supplemental” CBT tools the authors believe are useful to consider when treating complicated PTSD cases. These include: DBT concepts and skills, activity scheduling, assertiveness, communication skills, problem solving, exposure for co-morbid anxiety difficulties, treatment for sleep problems, and eating disorders. It is only a brief review and the authors advise clinicians to further develop their awareness and knowledge of how to utilize these tools. The last chapter offers guidance in handling treatment stumbling blocks. Issues covered include: decision making when treatment does not proceed as planned, planning for termination of treatment, generalization and maintenance of gains.

This book is probably best suited for clinicians with some knowledge of CBT but who are inexperienced in its application to PTSD. However, experienced clinicians will also find it a useful review and resource. Through use of detailed clinical examples the authors have illustrated the practicalities of applying exposure and cognitive restructuring techniques in a clear and easy to follow manner. Many examples of worksheets and handouts for use with patients are included in the chapters focusing on treatment. It is an excellent addition to the PTSD treatment literature. Recommended.