When I give talks or workshops, participants often ask about therapies they have heard of that have been advocated by charismatic speakers who are convinced of the success of their newest treatments for posttraumatic stress disorder (PTSD). What I always want to know is whether this therapy has been studied in randomized controlled trials, replicated by other researchers, and then found to be effective in practice settings.
Why is this important? Because it appears that most people show at least some improvement with any treatment for PTSD. Nonspecific effects of treatment can be quite powerful because one of the most important factors in maintaining PTSD is avoidance of trauma memories, emotions, or reminders. Taking regular time to work on one’s trauma memories and PTSD, traveling to a therapy session (or taking the time to set up a telehealth appointment), thinking about one’s traumas and symptoms, and talking to a caring listener are all blocking automatic avoidance responses. When avoidance decreases, memories, emotions, and thoughts emerge that can be explored more objectively. Just these actions can result in some improvement in symptoms. The question about new treatments for PTSD is whether they exceed the improvements from these nonspecific effects of supportive treatment and at least equal the treatments that have stood the test of time.
There are important reasons to conduct randomized clinical trials. Unlike medication trials, in which patients and providers can be blinded from knowing whether the patient has received the active medication or a placebo, psychotherapy trials cannot be blinded. The patient and therapist know what treatment is being provided. As many other variables as possible need to be controlled beyond random assignment to conditions. The therapy or therapies need to be conducted the same way with fidelity to the treatment and with competence of the therapist. This requires treatment manuals and training to achieve a level of competence and supervision to minimize therapist drift.
Therapy sessions are recorded so that independent evaluators can rate both adherence and competence and that they are equal across therapies. Assessments must be valid and reliable and given at regular intervals. Diagnostic interviews also need validity checks. Sample sizes need to be large enough to find differences if they exist. A comparison condition must be established to control for time, nonspecific therapy, or other competing therapies. By controlling these variables across the study conditions, one can have more assurance that any differences found between the therapies (or waitlist) are correct. Of course, this is where replication, especially outside of the researchers’ lab takes over.
So the question remains, whether one of the fad therapies that are presented at conferences or in books with no solid research behind it should be implemented with patients with PTSD. Just because a speaker sounds compelling does not mean that a therapy works better than the nonspecific effects of treatment or the charm of a particular therapist. One solution to the question of which therapies to learn and implement comes from treatment guidelines. For more than a decade, groups of scholars independent of the therapies, working with organizations, have evaluated the efficacy and effectiveness of various therapies (including, in some cases, medication) for PTSD and reported on the treatments with the best evidence.
Overall, guidelines from the Phoenix Australia Centre for Posttraumatic Mental Health (Phoenix Australia, 2013), the American Psychological Association (APA, 2017), the International Society for Traumatic Stress Studies (ISTSS, 2018), the National Institute for Health and Care Excellence (NICE, 2018), and the U.S. Department of Veterans Affairs and Department of Defense (VA/DoD, 2023) converge on recommending trauma-focused cognitive behavioral therapies (CBTs) as the first-line intervention for PTSD. In the most recent update with the VA/DoD treatment guidelines, specific treatments were named, not just the generic term “trauma-focused treatments,” which means that the therapy addresses the traumatic events directly and doesn't just focus on current symptoms and issues. However, these trauma-focused CBTs are considered first line, prioritizing over medication.
The VA/DoD guidelines specifically recommended prolonged exposure (PE), cognitive processing therapy (CPT), and eye movement desensitization and reprocessing (EMDR) with the greatest strength of evidence. They listed with weaker evidence cognitive therapy for PTSD (CT-PTSD), present-centered therapy (PCT), and written exposure therapy (WET). Currently among the strongly recommended treatments, there have been no differences found between them and there are no predictors of which type of patient characteristics would recommend one treatment over the other. If therapists are trained in at least one of these treatments or more, then patients can be given a choice with some confidence. If therapists can implement more than one of these therapies with competence and fidelity, then they can describe the choices, and the patient can pick one that is most appealing to them.
The NICE guidelines were a bit different. They recommended CPT, CT-PTSD, narrative exposure therapy (NET), and PE. They were somewhat more tentative about EMDR, recommending it for civilian populations (noncombat-related) and more than three months posttrauma. They were also concerned that EMDR was not always implemented in a consistent way, so they suggested that a consistent structure and content be determined by research and expert consensus.
When there are therapies available that have had cumulative studies numbering in the hundreds and shown to have lasting effects up to 10 years, it then becomes a matter of ethics if an evidence-based therapy is not offered. The onus is on the advocate for a new therapy to conduct the research (or find groups of colleagues with the skills to do so) to demonstrate that a therapy is effective with randomized controlled trials and then applied studies. They need to demonstrate that their approach has a greater effect than nonspecific effects of treatment and at least as well as recommended treatments. In the meantime, it is the therapists’ obligation to either learn to conduct the recommended treatments or to refer patients to those who can provide them. Therapists should not be practicing outside their scope of expertise.
References
American Psychological Association (APA). (2017). Clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults.
International Society for Traumatic Stress Studies (ISTSS). (2018). ISTSS PTSD prevention and treatment guidelines: Methodology and recommendations.
National Institute for Health and Clinical Practice (NICE). (2018). Guideline for post‑traumatic stress disorder. London: Author.
Phoenix Australia Centre for Posttraumatic Mental Health (Phoenix Australia). (2013). Australian guidelines for the treatment of acute stress disorder and posttraumatic stress disorder. Melbourne: Author.
Why Are There So Many Treatments for PTSD, and How Do I Choose?
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29.04.2024
When I give talks or workshops, participants often ask about therapies they have heard of that have been advocated by charismatic speakers who are convinced of the success of their newest treatments for posttraumatic stress disorder (PTSD). What I always want to know is whether this therapy has been studied in randomized controlled trials, replicated by other researchers, and then found to be effective in practice settings.
Why is this important? Because it appears that most people show at least some improvement with any treatment for PTSD. Nonspecific effects of treatment can be quite powerful because one of the most important factors in maintaining PTSD is avoidance of trauma memories, emotions, or reminders. Taking regular time to work on one’s trauma memories and PTSD, traveling to a therapy session (or taking the time to set up a telehealth appointment), thinking about one’s traumas and symptoms, and talking to a caring listener are all blocking automatic avoidance responses. When avoidance decreases, memories, emotions, and thoughts emerge that can be explored more objectively. Just these actions can result in some improvement in symptoms. The question about new treatments for PTSD is whether they exceed the improvements from these nonspecific effects of supportive treatment and at least equal the treatments that have stood the test of time.
There are important reasons to conduct randomized clinical trials. Unlike medication trials, in which patients and providers can be blinded from knowing whether the patient has received the active medication or a placebo, psychotherapy trials cannot be blinded. The patient and therapist know what treatment is being provided. As many other variables as possible need........
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