Reference Adshead and FerrisAdshead & Ferris (2007) emphasise how cognitive–behavioural approaches have become established as the core to treatment and quote recent National Institute for Health and Clinical Excellence (NICE) guidelines to support this (National Collaborating Centre for Mental Health, 2005). They are also clear that there are other models available for complex presentations of trauma-related pathology. It is unfortunate that NICE guidelines do not address the issues of the significant proportion of patients who discontinue treatment (which can average over 20%) or fail to respond. Cognitive–behavioural approaches continue to develop, with metacognitive therapy in particular seeking to address these issues (Reference Wells and SembiWells & Sembi, 2004).

The development of cognitive–behavioural approaches that are primarily based not on exposure but on addressing individuals' difficulties in processing their response to trauma suggests the possibility of a rapprochement between different theoretical and therapeutic models. This would inform stepped-care approaches (Reference Bower and GilbodyBower & Gilbody, 2005) supporting appropriate matching of patient need and problem complexity with services and intervention.