Can I treat my client when they might be re-exposed to trauma?

This question was examined by Naomi Ennis, Iris Sijercic and Candice Monson in their systematic review: Trauma-focused cognitive-behavioral therapies for posttraumatic stress disorder under ongoing threat, published in 2021.

Enis and colleagues highlighted that there is debate about using trauma focused therapy during risk of trauma reexposure when objective safety is not guaranteed, and that many experts argue that a safe and stable situation is necessary for PTSD treatment to be successful.  However, in contrast others suggest that treatment is a priority because symptoms interfere with the ability to distinguish safety and increase risk of revictimization. Similarly, they reported that the literature shows clinicians are providing therapy for PTSD in these situations.

Due to the lack of publications in the area Enis and colleagues used broad search terms. They obtained 3750 articles which they reduced to 21 relevant articles that met the following criteria:

1) Therapy was delivered to a sample in a situation of ongoing threat of reexposure to a DSM Criterion A trauma, as explicitly stated by the authors

2) All participants had a diagnosis of PTSD or clinically significant PTSD symptoms

3) PTSD was a treatment target

4) PTSD symptoms were reported as an outcome measure and assessed before and after the intervention

5) The intervention was developed within a CBT framework and implemented cognitive (e.g., thought records) and/or behavioral techniques (e.g., exposures) with a trauma focus (e.g., focused on processing of the trauma, exposure to trauma-related stimuli).

What were the dangers?

Potentially traumatic events that participants may be reexposed to during treatment included:

  • Seeing a dead body
  • Having their home shelled
  • Being forced to stay in a basement during shelling
  • An armed person forcibly entering their home
  • Family members injured due to war or community violence
  • Fire fighting
  • Active military duty
  • Domestic violence or intimate partner violence



As is often the case with research the finds are mixed and inconclusive. Nevertheless, there were some findings that are useful for clinicians to consider.

“The effect sizes found across studies in this review were comparable to those found for trauma-focused CBTs for PTSD in general clinical populations.” pg 8

“There was also no evidence that therapy techniques may habituate individuals to real danger cues, putting them at risk of reexposure to trauma” pg 9

“Data from this review suggest that safety planning and helping clients differentiate between real danger and trauma reminders may be a key modification to CBTs for PTSD applied to individuals under ongoing threat.” pg 10

“Data from this emerging literature do not support the notion that trauma-focused CBTs for PTSD are contra indicated for individuals at risk of ongoing threat and point to their potential usefulness in treating PTSD.” pg 10


Ennis, N., Sijercic, I., & Monson, C. M. (2021). Trauma-focused cognitive-behavioral therapies for posttraumatic stress disorder under ongoing threat: A systematic review. Clinical psychology review88, 102049. Advance online publication.