Hyperbaric oxygen for brain injury and PTSD (contested)

1. Introduction

Version followed: US regulatory and federal positions as of October 2026 (FDA 510(k) clearance of hyperbaric chambers; FDA consumer update on unproven HBOT claims, 2013, as reported; FDA letter to health care providers, 25 August 2025; VA/DoD PTSD guideline 2023 and mTBI guideline 2021 as cited by VA and DoD; VA Community Care Clinical Determination 00075, effective 1 July 2026; DoD TBI Center of Excellence information paper, March 2025). Claims for benefit are those of the Israeli group led by Shai Efrati (Sagol Center for Hyperbaric Medicine and Research, Shamir Medical Center / Tel Aviv University), principally the randomized sham-controlled trial by Doenyas-Barak et al. (J Clin Psychiatry, 2024).

Status: contested. Hyperbaric oxygen therapy (HBOT) means breathing pure oxygen inside a pressurized chamber. It is an established hospital treatment for a defined list of conditions (e.g. decompression sickness, carbon monoxide poisoning, gas embolism, certain non-healing wounds and radiation injury), but it is not FDA-cleared for traumatic brain injury (TBI), post-concussion symptoms or PTSD, and US federal health systems currently treat it as investigational for these uses [source: FDA letter 2025; Harvard Health; TBICoE 2025; VA CDI 00075]. It is a medical procedure delivered by hyperbaric medicine teams, not by psychotherapists. This guide is written for the psychotherapist working alongside that team, or with a client or veteran who is considering or receiving HBOT elsewhere. No treatment pressures, durations, session counts or protocols are given.

The proponents' theory of change (attributed, not established). The Efrati group proposes that their HBOT protocol may "activate mechanisms that repair the wounded brain tissue", including stem-cell activity and new blood-vessel formation, and reports changes in brain connectivity on imaging alongside symptom improvement [source: Tel Aviv University press release, 22 Feb 2022; Doenyas-Barak et al. 2024]. US federal reviewers judge this evidence insufficient for clinical use (see Section 2). For the psychotherapist, the relevant change processes are ordinary ones: informed, unpressured decisions; continued access to evidence-based PTSD and TBI care; and good monitoring and communication with the medical team [synthesis].

2. Framework

2.1 Regulatory and evidence status (date checked: October 2026)

FDA (US). Hyperbaric chambers are Class II devices cleared through the 510(k) pathway (product code CBF) [source: FDA letter to health care providers, 25 Aug 2025]. FDA has cleared chambers for 13 uses, among them air or gas embolism, carbon monoxide poisoning, decompression sickness and thermal burns [source: FDA consumer update 2013 as reported by MD+DI and RAPS, 22 Aug 2013; TBICoE 2025 also cites 13 cleared conditions]. FDA's 2013 consumer update warned that HBOT has not been shown to be safe and effective for conditions it has been marketed for, a list that includes brain injury, depression, stroke, Alzheimer's disease, cerebral palsy, migraine and spinal cord injury (PTSD is not named); it noted risks ranging from sinus and ear pain to air embolism and fire; and it warned that using HBOT in place of proven treatment can endanger health, advising people to discuss all options with their health care professional first [source: FDA consumer update 2013 as reported by MD+DI and RAPS] [uncertain: FDA wording as reported by trade press]. "The FDA has not indicated or cleared HBOT for the treatment of TBI or postconcussion symptoms" [source: TBICoE 2025]. PTSD is not among the cleared uses [source: VA CDI 00075; PHCoE 2021].
FDA safety communication (2025). FDA warned of fires in HBOT devices causing serious injuries and deaths and urged facilities to follow manufacturer instructions, fire-safety and grounding measures, staff training and continuous patient supervision [source: FDA letter 2025].
VA/DoD PTSD guideline (2023). Does not recommend for or against HBOT for PTSD because evidence is insufficient; its Recommendation 24 lists hyperbaric oxygen therapy among somatic therapies with insufficient evidence for or against use in PTSD [source: VA CDI 00075; Schnurr et al. 2024, Annals of Internal Medicine synopsis of the guideline]; the 2017 edition had said the same [source: PHCoE Evidence Brief 2021]. Trauma-focused psychotherapies (CPT, PE, EMDR) remain the primary PTSD treatment approach [source: VA CDI 00075].
VA/DoD mTBI guideline (2021). "Recommends against the use of HBOT" for symptoms attributed to mild TBI [source: TBICoE 2025]. A 2018 DoD Health Affairs memorandum concluded HBOT should not be prescribed for persistent post-concussion symptoms [source: TBICoE 2025].
VA coverage. VA Community Care Clinical Determination 00075 (effective 1 July 2026) classes HBOT for PTSD and TBI as "investigational and experimental" and not covered, citing insufficient evidence on safety and efficacy [source: VA CDI 00075]. TBICoE (March 2025) states HBOT for TBI is not covered through VA or TRICARE [source: TBICoE 2025]. Earlier, in November 2017, VA announced HBOT for a small number of veterans with chronic PTSD who had not responded optimally to at least two evidence-based therapies, at two VA systems (Eastern Oklahoma; Northern California) with outside partners, described by officials as off-label and paired with research [source: VA Community Care page 29 Nov 2017; Military Times 29 Nov 2017]. Whether that programme still operates is [uncertain]; the 2026 coverage determination suggests clients should not assume VA will fund HBOT for these conditions.
DoD evidence summaries. PHCoE (March 2021) found the evidence insufficient and called for adequately sham-controlled RCTs [source: PHCoE 2021]. TBICoE (March 2025) concluded the evidence does not support HBOT for TBI or post-concussion symptoms and noted that benefits in some studies faded at later follow-up [source: TBICoE 2025]. A 2015 VA/DoD review led by Col. Scott Miller found little evidence of benefit for TBI and PTSD and recommended against reimbursement [source: Military Times 2017].
Proponents' trial evidence. Doenyas-Barak, Kutz, … Efrati (2024) randomized 63 male Israeli combat veterans with treatment-resistant PTSD and no TBI history to HBOT or sham (56 completers); they report much higher responder and remission rates with HBOT than sham, plus imaging changes; the authors note a small sample and short follow-up [source: Doenyas-Barak et al. 2024]. Efrati co-founded a company that applies these protocols commercially [source: TAU press release 2022]. The same group has also published on brain injury and post-concussion symptoms [uncertain: those papers are not reviewed here]. These claims are attributed to the authors and are contested by US federal reviewers.
Other jurisdictions (UK, EU, Australia). Not covered in this guide [uncertain]; ask the treating physician what applies locally.

2.2 Who delivers it

Hyperbaric medicine physicians and trained chamber staff in a hyperbaric facility; FDA expects staff training and continuous supervision [source: FDA letter 2025], and FDA recommends treatment only at accredited facilities [source: Harvard Health]. The psychotherapist does not prescribe, schedule or deliver HBOT.

2.3 Phases of the psychotherapist's involvement [synthesis]

Inquiry (often one session or part of one): the client raises HBOT. Goal: understand their hopes, sources and stakes. Move on when you know what the client is considering and why.
Informed decision support (one to three sessions, alongside ongoing therapy): balanced information, questions for the medical team, consent support, review of evidence-based alternatives. Move on when the client has made a decision with a physician, or decided against it.
During a course (if the client proceeds with a medical team): continue psychotherapy, monitor psychological and physical warning signs, liaise with the team with consent. Move on when the course ends or stops.
After: review outcomes and expectations, consolidate or resume evidence-based PTSD/TBI treatment, follow up on disappointment or new symptoms.

Format: individual sessions within the existing therapy; liaison by letter or call to the hyperbaric physician or primary care with written consent [synthesis].

3. Guiding principles

Name it as contested. Say plainly that HBOT is established for some medical conditions but not cleared or recommended for PTSD or TBI in the US; meaning: no hedged endorsements, no dismissive scorn [source: Section 2 sources; framing synthesis].
Attribute every claim. "The Israeli group led by Efrati reports …"; "the VA and DoD guidelines say …"; meaning: the client can see who says what [synthesis].
Stay in your scope. You do not recommend, prescribe or advise for or against a medical procedure; meaning: route medical questions, eligibility and risk screening to a physician [synthesis].
Protect access to proven care. FDA's chief concern was patients delaying or forgoing proven therapies [source: FDA consumer update 2013 as reported by RAPS]; meaning: keep trauma-focused psychotherapy (CPT, PE, EMDR) on offer before, during and after [source: VA CDI 00075].
Respect autonomy. Adults may choose an unproven option after informed discussion; meaning: support the decision process, not a particular outcome [synthesis].
Informed consent is the treating team's legal duty; supporting it is yours. Meaning: help the client prepare questions and understand answers; do not stand in for the physician's consent discussion [synthesis].
Safety first. Fire, barotrauma and oxygen-related seizures are documented risks [source: FDA letter 2025; Mayo Clinic; Harvard Health]; meaning: encourage only regulated, supervised medical facilities and full disclosure of medical history to the team.
Watch the mind as well as the body. In the 2024 trial some HBOT participants reported resurfacing traumatic memories with several days of distress [source: Doenyas-Barak et al. 2024]; meaning: plan for trauma activation and suicide risk monitoring.
Be alert to financial and hope-driven pressure. Treatment is costly and usually not covered for these indications [source: TBICoE 2025; VA CDI 00075]; meaning: explore cost, debt and desperation openly [synthesis].
Collaborate with consent. Meaning: share relevant psychological information with the hyperbaric and primary teams only with written permission, except in emergencies under local law [synthesis].
Hold the long view. DoD reviewers report benefits in some studies faded at follow-up [source: TBICoE 2025]; meaning: plan for the period after the course regardless of outcome.

4. Intervention inventory

Part A describes how the medical team delivers HBOT, at a descriptive level only, so you can prepare and support the client. Part B lists the psychotherapist's own interventions.

A1. How HBOT is delivered (descriptive, as official and clinical sources describe it)

Purpose: to let you explain the experience accurately and anticipate psychological reactions; not for the client to arrange or replicate treatment.
Steps (what the client will meet): A physician-led hyperbaric service decides whether treatment is appropriate. Treatment takes place either in a monoplace chamber (a single-person clear tube the patient lies in, filled with pressurized oxygen) or a multiplace chamber (a room for several people, who breathe oxygen through a mask or clear hood) [source: Mayo Clinic, Dec 2024]. Patients wear hospital-approved gowns or cotton clothing; lighters, heat-producing battery devices, hair and skin products and makeup are excluded, and nothing enters the chamber without staff approval [source: Mayo Clinic; FDA letter 2025]. Staff monitor the patient throughout [source: Mayo Clinic; FDA letter 2025]. Ear pressure or fullness is common and staff teach ways to relieve it such as swallowing or yawning; ears, blood pressure and pulse are checked afterwards, and tiredness or hunger may follow [source: Mayo Clinic]. Facilities are expected to follow manufacturer instructions, fire-prevention, grounding and staff-training requirements [source: FDA letter 2025]. Specific protocols, pressures and course length are set by the treating physician and are not given here.
Example language (illustrative): "From what the hospital sources describe, you'd either lie in a clear single-person tube or sit in a room with others wearing a hood or mask, with staff watching the whole time. Let's think about how being enclosed like that might feel for you."
Watch for: confinement, masks or hoods acting as trauma reminders (e.g. for veterans); clients considering non-medical, wellness-centre or home "soft" chambers; any suggestion of skipping disclosure of medical conditions [synthesis].

A2. Documented risks to know and pass on (as sources state them)

Purpose: to support informed consent and recognise warning signs you should route to the team.
Steps: Know the documented risks: ear pain and middle-ear injury including eardrum rupture; sinus pressure, pain or nosebleeds; short-term vision changes and, with long courses, cataract formation; short-term decline in lung function; low blood sugar in people with insulin-treated diabetes; rarely lung collapse; and seizures from excess oxygen in the central nervous system [source: Mayo Clinic]. Harvard Health lists ear and sinus pain, eardrum rupture, rare lung collapse and temporary vision changes [source: Harvard Health]. Fire is a heightened risk in high-oxygen environments, and FDA has received reports of HBOT fires causing serious injuries and deaths [source: FDA letter 2025]. Anxiety in enclosed spaces is common enough that teams ask about it [source: Mayo Clinic]. In the 2024 Israeli trial, self-resolving barotrauma occurred in both arms and seven HBOT participants reported resurfacing memories with distress lasting several days [source: Doenyas-Barak et al. 2024].
Example language (illustrative): "The medical sources list some physical risks, mostly ear and sinus problems, and rarer ones like seizures and fire. Those are questions for the hyperbaric doctor, and it would help to ask how their unit manages them."
Watch for: any report of seizure, chest pain or breathing difficulty, ear injury, vision change or hypoglycaemia: these go to the treating physician or emergency services, not to therapy [synthesis].

B1. Responding when a client or veteran asks about HBOT

Purpose: keep the alliance and gather information when HBOT comes up (often from peers, veterans' groups, media or clinic advertising).
Steps: (1) Thank them for raising it. (2) Ask what they have heard, from whom, and what they hope it will change. (3) Ask what has been tried so far for PTSD or TBI and how it went. (4) Ask about costs being quoted and the setting (hospital unit vs wellness centre). (5) Say you will give balanced information and that the medical decision belongs with a physician. (6) Agree to return to it next session if needed [synthesis].
Example language (illustrative): "I'm glad you told me. What have you heard about it, and what would be different for you if it worked?"
Watch for: hopelessness about therapy ("nothing else works"), urgency or pressure from family or peers, large prepayments. Working: the client talks openly and asks questions rather than seeking permission or rebuttal [synthesis].

B2. Balanced psychoeducation on status and evidence

Purpose: give an accurate, attributed picture so the client can weigh it.
Steps: Cover, briefly: (1) HBOT is a real medical treatment, FDA-cleared for specific conditions; (2) it is not FDA-cleared for TBI, post-concussion symptoms or PTSD [source: TBICoE 2025; VA CDI 00075]; (3) the VA/DoD 2023 PTSD guideline neither recommends for nor against it (insufficient evidence); the 2021 mTBI guideline recommends against it [source: VA CDI 00075; TBICoE 2025]; (4) VA's 2026 community-care determination classes it as investigational and not covered for PTSD and TBI [source: VA CDI 00075]; (5) an Israeli group led by Efrati reports positive sham-controlled results in a small trial of veterans with treatment-resistant PTSD, with the authors noting small numbers and short follow-up, and the lead investigator has a commercial interest [source: Doenyas-Barak et al. 2024; TAU 2022]; (6) evidence-based trauma-focused therapies remain first-line [source: VA CDI 00075]. Offer the sources in writing [synthesis].
Example language (illustrative): "This is genuinely disputed. One Israeli research team reports good results in a small trial; the VA and Department of Defense reviews say the evidence isn't strong enough yet, and the VA doesn't cover it for PTSD or brain injury."
Watch for: the client hearing only the positive or only the negative; check understanding with teach-back [synthesis].

B3. Supporting informed consent and shared decision-making

Purpose: help the client reach a decision that is informed, voluntary and their own, without you making it.
Steps: (1) Help the client write questions for the hyperbaric physician, e.g. Is this use FDA-cleared? What evidence does the unit rely on? Who supervises each session? Is the facility accredited and how does it manage fire risk? What are the risks for me given my history? What will it cost and is it covered? What happens if I want to stop? How will outcomes be measured and shared? [source for safety and accreditation items: FDA letter 2025; Harvard Health; question list synthesis]. (2) Encourage disclosure of all medical history to the team, including diabetes, ear or sinus problems and claustrophobia [source: Mayo Clinic], and any seizure history or lung problems [synthesis, given listed risks]. (3) Explore values: what matters most (symptom relief, cost, time, risk). (4) Check voluntariness: pressure from others, desperation, financial strain. (5) Document that you discussed it and that medical advice was directed to a physician [synthesis].
Example language (illustrative): "My job isn't to decide this for you. Let's make sure you have the questions you need to ask the doctor and that the choice feels like yours."
Watch for: decisions made in a crisis; a clinic that discourages questions or offers no physician consultation; the client expecting you to sign off. Working: the client can state the potential benefits, risks, costs and alternatives in their own words [synthesis].

B4. Avoiding endorsement (and avoiding dismissal)

Purpose: keep within scope and preserve trust whatever the client decides.
Steps: (1) Do not recommend, refer to, or provide letters supporting HBOT for PTSD or TBI as a psychological treatment; route requests to a physician [synthesis]. (2) Do not ridicule the client's interest; acknowledge that people they trust may have reported benefit. (3) Disclose any personal or financial connection to a provider. (4) If an HBOT provider asks you to promote their service or supply testimonials, decline [synthesis].
Example language (illustrative): "I can't recommend it either way because it's a medical procedure outside my training, but I'll keep working with you whichever way you go."
Watch for: your own reactions (scepticism or hope) leaking into the conversation; take them to supervision [synthesis].

B5. Recognising when to suggest medical review, referral and collaborative care

Purpose: ensure medical questions, TBI assessment and HBOT screening sit with the right professionals.
Steps: (1) Suggest the client discuss HBOT with their primary physician or a hyperbaric medicine physician before committing. (2) For suspected or known TBI, ensure assessment and follow-up through a physician or TBI service; the VA/DoD mTBI guideline recommends against HBOT for mTBI symptoms [source: TBICoE 2025]. (3) With written consent, send a short letter to the treating physician noting the PTSD diagnosis, current therapy, relevant psychological risks (confinement anxiety, trauma reminders, suicide risk history) and your contact details. (4) Agree with the client what will be shared both ways [synthesis].
Example language (illustrative): "Would it help if, with your permission, I let the hyperbaric doctor know you're in therapy with me and that enclosed spaces can be hard for you?"
Watch for: providers outside medical settings with no physician involvement; no channel for sharing concerns. Working: named contacts on both sides and agreed communication [synthesis].

B6. Keeping evidence-based PTSD treatment in place

Purpose: prevent HBOT from replacing proven care, the risk FDA highlighted [source: FDA consumer update 2013 as reported by RAPS].
Steps: (1) Review which trauma-focused therapies (CPT, PE, EMDR) the client has had, at what adequacy, and with what barriers [source for the therapies named: VA CDI 00075]. (2) Offer, or refer for, a trauma-focused therapy not yet adequately tried. (3) If the client proceeds with HBOT, agree whether to continue, pause or schedule trauma-focused work, coordinating timing with the medical team rather than stopping therapy by default [synthesis]. (4) Keep any medicines under the prescriber's management; do not advise changes.
Example language (illustrative): "Whatever you decide about the chamber, I'd like us to keep the therapy that has the strongest evidence for PTSD on the table. Shall we look at what's been tried and what hasn't?"
Watch for: the client dropping therapy because a "brain fix" is expected; earlier therapies abandoned early for avoidable reasons. Working: a written plan covering both strands [synthesis].

B7. Preparing for confinement anxiety and trauma reminders

Purpose: reduce the chance that the chamber experience becomes overwhelming or retraumatising.
Steps: (1) Use the A1 description to explore specific triggers: enclosure, lying in a tube, a hood or mask over the face, noise, staff out of reach [synthesis]. (2) Rate anticipated distress and identify personal reminders (e.g. confined vehicles, gas masks, detention). (3) Rehearse grounding and paced-breathing skills the client already knows; do not coach any technique that conflicts with the team's breathing or ear-clearing instructions [synthesis]. (4) Encourage the client to tell the hyperbaric team about claustrophobia, which teams ask about and can address [source: Mayo Clinic]. (5) Agree a clear rule: if distress becomes unmanageable, the client tells staff at once and decides with them what happens next; never "push through" against the team's advice [synthesis].
Example language (illustrative): "If being enclosed brings back something from your deployment, what will you notice first, and what will you say to the staff?"
Watch for: dissociation history, panic disorder, severe claustrophobia. Working: the client has a plan they can describe and has told the team [synthesis].

B8. Monitoring during a course and passing on warning signs

Purpose: catch psychological deterioration and route physical warning signs to the medical team.
Steps: (1) Track PTSD and depression symptoms with the validated self-report measures you already use (e.g. the PCL-5 used in VA settings), at baseline and regularly; describe change to the client without overinterpreting [synthesis]. (2) Ask each session about intrusive memories and their intensity: the 2024 trial reported resurfacing memories with distress lasting several days in some HBOT participants [source: Doenyas-Barak et al. 2024]. (3) Screen for suicidal thoughts at each contact during periods of increased distress, using your service's standard risk assessment [synthesis]. (4) Ask about physical effects (ear or sinus pain, vision changes, breathing problems, low blood sugar, any seizure) and direct the client to the hyperbaric team or emergency care; with consent, inform the team yourself [source for listed effects: Mayo Clinic; routing synthesis]. (5) Note sleep, substance use, finances and relationships.
Example language (illustrative): "Some people in one study had old memories come up strongly for a few days. Has anything like that happened for you this week?"
Watch for: rising intrusions, nightmares, avoidance of the chamber or of therapy, increased alcohol use, hopelessness if early sessions bring no change. Working: the client reports changes early and both teams know about significant ones [synthesis].

B9. Working with memories or emotions that surface

Purpose: help the client process trauma material that emerges during the course, within the safety of therapy.
Steps: (1) Validate and normalise that material can surface. (2) Stabilise first: grounding, sleep and safety review. (3) If the client is in, or ready for, a trauma-focused therapy, bring the material into that structure (e.g. the hotspot or target work of the chosen protocol) rather than unstructured exploration. (4) If the client is destabilised, slow down, increase contact and inform the medical team with consent [synthesis throughout; whether and how the Efrati group integrates psychotherapy with HBOT was not verified here, so [uncertain]].
Example language (illustrative): "It makes sense that this memory came back. Let's first help your body settle, then decide together whether we work with it today or next time."
Watch for: flooding, dissociation, self-harm urges. Working: distress peaks then falls and the client can talk about the memory with less avoidance [synthesis].

B10. Crisis and safety planning

Purpose: keep the client safe if the course, its cost or its outcome raises risk.
Steps: (1) Review or write a safety plan before the course: warning signs, coping steps, people and places, professional and crisis contacts (e.g. in the US the 988 line, Press 1 for veterans) [synthesis]. (2) Include lethal-means counselling on safe storage, especially firearms for veterans [synthesis]. (3) Plan for high-risk moments: the course ending, lack of improvement, debt. (4) Know how to reach the hyperbaric unit and the client's physician out of hours.
Example language (illustrative): "Let's update your safety plan before you start, so it covers a hard week in treatment or a disappointing result."
Watch for: hopelessness framed as "this was my last chance" [synthesis].

B11. Brain-injury-specific collaboration

Purpose: ensure clients with TBI receive guideline-based care and that cognitive symptoms are tracked.
Steps: (1) Encourage assessment by a physician or TBI service and, where indicated, neuropsychological and rehabilitation input [synthesis]. (2) Explain, attributed, that the VA/DoD mTBI guideline recommends against HBOT for mTBI symptoms and FDA has not cleared it for TBI [source: TBICoE 2025]. (3) Adapt therapy for cognitive difficulties: shorter segments, written summaries, reminders [synthesis]. (4) Distinguish PTSD and post-concussion symptoms in your formulation and share with the team.
Example language (illustrative): "Head injury and PTSD can cause overlapping problems. Let's make sure a doctor who knows brain injury has assessed you, whatever you decide about the chamber."
Watch for: worsening headache, confusion or new neurological symptoms: urgent medical review [synthesis].

B12. Support after the course ends

Purpose: consolidate gains, manage disappointment and keep the client in care.
Steps: (1) Review outcome measures and the client's own sense of change. (2) If improvement is reported, help the client use it (e.g. engaging in trauma-focused work) and watch for later fading, which DoD reviewers note occurred in some studies [source: TBICoE 2025]. (3) If there was no benefit, explore disappointment, shame or anger without "I told you so"; DoD reviewers note that offering treatments with insufficient evidence can lead to mistrust when expectations are not met [source: TBICoE 2025]. (4) Reconnect to evidence-based options and update the safety plan [synthesis].
Example language (illustrative): "You took a big step trying this. Whatever changed or didn't, let's look at where you are now and what comes next."
Watch for: pursuit of repeated or escalating unproven treatments, debt, withdrawal from care [synthesis].

B13. Documentation and consultation

Purpose: protect the client and you.
Steps: Record the discussion, information and sources given, that medical questions were referred to a physician, consent for any liaison, and risk reviews. Seek supervision or ethics consultation if pressured to endorse or if the client's choice raises safeguarding concerns [synthesis].
Example language (illustrative): "I'll note that we talked about this and that the medical decision is with your doctor."
Watch for: notes implying you recommended the treatment [synthesis].

5. Handling problems

The official and trial sources do not address the psychotherapist's problems directly; except where a source is tagged, this section is [synthesis].

The client wants you to endorse it or write a supporting letter. Explain your scope; offer a factual letter confirming diagnosis and current treatment (with consent), routed to a physician, without recommending HBOT. Illustrative: "I can confirm you're in treatment with me for PTSD; whether HBOT is right for you is a medical decision."
The client is angry that you are "against" it. Repair the rupture: acknowledge you may have sounded dismissive, restate that the evidence is disputed and attributed, and that you will keep working with them either way. Ask what would help them feel respected.
"Nothing else has worked." Validate exhaustion; review what was actually tried and how adequately; offer a different trauma-focused therapy, intensive formats or a specialist service; treat hopelessness as a risk indicator and assess suicide risk.
Stuck in research loops or online forums. Agree a limited time to gather information, a short list of questions for the physician, and a decision point; return therapy time to valued goals.
Overwhelm during the course (intrusions, nightmares, panic in the chamber). Increase session frequency, stabilise, update the safety plan, and with consent tell the hyperbaric team; resurfacing distressing memories were reported in the 2024 trial [source: Doenyas-Barak et al. 2024]. Never advise the client to stop or continue the course: they decide with the physician.
Non-adherence to psychotherapy because HBOT is expected to fix things. Name the pattern without blame; explore expectations; propose a minimal therapy contact (e.g. monitoring sessions) so care is not lost.
Non-medical or wellness-centre chambers, home chambers or untrained staff. Share, attributed, that FDA links fire risk to high-oxygen environments and expects trained staff, supervision and safety procedures, and that FDA recommends accredited facilities [source: FDA letter 2025; Harvard Health]; encourage the client to ask their physician before using any such service.
Financial harm. Explore costs, prepayment and borrowing; note that VA and TRICARE do not cover HBOT for these conditions [source: VA CDI 00075; TBICoE 2025]; involve a financial counsellor or benefits adviser if needed.
Family or peers pressing for or against it. Offer a joint session focused on the client's values and information needs; keep the decision with the client and physician.
Physical warning signs reported in session (seizure, chest pain, breathlessness, ear injury, vision change, hypoglycaemia). Direct to the treating team or emergency services immediately [source for listed risks: Mayo Clinic].
Conflicting messages from the HBOT clinic and VA/DoD. Lay both out with attribution (Efrati group vs VA/DoD reviews), name the commercial interest the lead investigator has disclosed [source: TAU 2022], and help the client weigh them with their physician.
Your own strong views. Use supervision; check your language for advocacy or ridicule.
Legislation or policy changes. Coverage and policy may change; bills on HBOT access for veterans appeared in the 119th Congress [uncertain: unverified]. Recheck VA and FDA pages before advising on status, and date your statements.

Sources

Sources (checked October 2026):

Cited indirectly [uncertain]: the FDA consumer update itself (2013; cited through the MD+DI and RAPS reports), the 2017 VA press release at news.va.gov, the VA/DoD 2021 mTBI guideline document (cited through VA and DoD summaries), and the Efrati group's brain-injury trials.

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