Is a trauma focus truly needed in PTSD treatment?

???????????????????????????????????????????????????????????????????????????????????????Last month Joris Haagen shared Part 1 of a saga around the question whether a trauma focus is truly necessary in trauma treatment. Based on a meta-analysis, Benish, Wampold and their colleagues concluded that the answer is No. Their analysis, and in particular the selection of studies, was heavily criticized by Ehlers et al. However, Wampold was not easily defeated and offered a riposte…Over to Joris:

Wampold et al. (2010) argue that their classification criteria are in fact more objective than previous meta-analyses and that the content of supportive therapies in research studies does not match supportive therapy as given in daily practice. For example, no therapist would normally dissuade their client from discussing traumatic experiences as is often the case in experimental studies. Wampold et al. also note that supportive interventions are difficult to capture in a single category because their content varies.

They further state that the distinction that Ehlers et al. make between trauma-focused and non-trauma-focused therapy is not clear-cut. TF-CBT has for instance considerable overlap with stress inoculation therapy (SIT) despite SIT not being considered trauma-focused. A neuro-feedback study is categorized as trauma-focused exposure, even though patients have no possibility to discuss traumatic content. Hypnotherapy and psychodynamic therapy are categorized as non-trauma-focused although both allow for – and even encourage – discussion of traumatic memories. As such, Wampold et al. stood by their view that the available research did not demonstrate the difference between trauma-focused and non-trauma-focused therapy.

Both groups display – at first glance – fundamentally different positions. On one side Benish and Wampold et al. consider all bona fide PTSD interventions to be equally efficacious. On the other side, Ehlers et al. believe this to be true only for trauma-focused PTSD interventions. The argument mainly revolves around the definition of an intervention. Both sides however acknowledge the need for additional research in alternative treatment interventions and express the wish to understand more about treatment mechanisms. And as simple as that, polarized viewpoints to some extent converge into similar outlooks.

Other fascinating articles have appeared since the publications of Benish, Ehlers and Wampold, shedding further light on the issue. A particularly compelling train of thought is provided by Barlow et al. (2013) who take the discussion beyond merely comparing the effectiveness of specific interventions based on the average responses of large treatment groups. Looking at averages ignores within-person variability (i.e., factors that influence treatment outcome). Barlow et al. emphasize the importance of individual treatment responses and promote the search for patient, therapist and contextual mechanisms of change as ‘the surest way to enhance efficacy’.

Barlow et al. also stress the importance of a greater understanding of common processes between similar disorders (a transdiagnostic approach) to develop new interventions.

Though differences between interventions are found, Gerger et al. (2014) and Watts et al. (2013) meta-analyses bridge the gap between Ehlers, Benish and Wampold by stating that

  1. differences in the effectiveness of different interventions were found,
  2. these differences were small and
  3. no interventions could be found that were consistently superior to most other interventions.

There is no single best treatment for PTSD. Guideline developers are even considering to include non-trauma-focused interventions (PCT) as preferred treatment choices.

Back to the question whether patients suffer needlessly from trauma-focused interventions? First, there is truth in both sides of the argument (Ehlers et al. vs. Benish and Wampold et al.). In my opinion the majority do not suffer needlessly due to trauma-focused therapy; these treatment approaches are the best proven ‘weapons’ against PTSD. However, differences between trauma-focused therapy and other proven non-trauma-focused interventions appear small. The trauma-focused versions may be slightly more effective, but the positive effects from patient preferences, the effects of dropout during therapy, or individual, contextual and therapist factors could outweigh this advantage. The heterogeneity in therapeutic outcomes between individual patients in PTSD treatment and meta-analyses argues for more investigation of within-subject factors that influence or predict treatment outcome. The times are changing and a zealous belief in the superiority of a trauma focus appears to be waning.

These articles are a proverbial treasure cove for the interested reader. They illuminate how the academic battle of conflicting opinions is fought. Opinions are formed, meticulously formulated and bolstered with empirical data, only to be broken down by the other party. New insights emerge from this process, such as the guideline recommendations by Ehlers et al. to increase the transparency and quality of future meta-analysis studies, and contributions by Wampold et al. concerning the role of therapists on therapeutic recovery. I would highly recommend to read these articles meticulously and discuss them with colleagues.

On a lighter note, just remember that the effectiveness of any specific intervention depends just for a small (roughly 30%) part on specific-components and for the most part on the non-specific variables present in all therapies as well as the natural course of events (Schnurr, 2007). Although this – of course – is also open to debate.

New references (see also Part 1):
Barlow DH, Bullis JR, Comer JS, & Ametaj AA (2013). Evidence-based psychological treatments: an update and a way forward. Annual review of clinical psychology, 9, 1-27 PMID: 23245338

Gerger, H., Munder, T., Gemperli, A., Nüesch, E., Trelle, S., Jüni, P., & Barth, J. (2014). Integrating fragmented evidence by network meta-analysis: relative effectiveness of psychological interventions for adults with post-traumatic stress disorder Psychological Medicine, 44, 3151-3164 DOI: 10.1017/S0033291714000853

Schnurr PP (2007). The rocks and hard places in psychotherapy outcome research. Journal of traumatic stress, 20, 779-92 PMID: 17955539

Watts BV, Schnurr PP, Mayo L, Young-Xu Y, Weeks WB, & Friedman MJ (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. The Journal of clinical psychiatry, 74 PMID: 23842024

Wampold BE, Imel ZE, Laska KM, Benish S, Miller SD, Flückiger C, Del Re AC, Baardseth TP, & Budge S (2010). Determining what works in the treatment of PTSD. Clinical psychology review, 30, 923-33 PMID: 20638168

These blogposts are adapted from Joris’ previous publication in the Dutch journal Cogiscope.

8 thoughts on “Is a trauma focus truly needed in PTSD treatment?

  1. I obviously need to review the studies covered above before saying anything specific about them, but I have generally found many of the assertions about “treatment” of PTSD to be seriously misconceived. I find it very striking that so many treatment models talk about symptom reduction. My impression is that this is the norm for Prolonged Exposure (PE). Ecker, Ticic, & Hulley (2012 – Unlocking the emotional brain) argue that PE and many other treatment models are extinction paradigms, and these do NOT eliminate trauma memories but create alternate responses to triggers, which responses need to be practiced else the treatment effect is eventually lost. In contrast, there are roughly 10-12 models which, if done right, ELIMINATE symptoms permanently. EMDR, which is what I use, does this, clearly (Ecler, et al., agree). We who use EMDR talk about curing PTSD, and I have a very high success rate with adult onset PTSD in those individuals who complete therapy – i.e., process ALL trauma memories.

    So, claims about most of the effect of treatment being due to non-specific factors simply does not match my experience at all, nor do claims that all PTSD treatment models are essentially equivalent. I am VERY concerned that people in need are being seriously misled by these claims. I’ve never had a single one of my clients return and say “My PTSD is back.”

    • I ask myself and you Tom: your skills and style of therapist, you capacity to create trust in a client through your involvement and compromise, to what degree does it cure the PTSD wound you treat with the tools EMDR gives to you?

      Have you some comments on that issue? Please share them if you want…

      • My apologies for taking so long to respond to you. I actually only just now saw your question.

        I have never failed to cure PTSD in an adult who has stayed with me, as long as their PTSD did not originate in childhood. THAT sort of PTSD is more difficult, and treatment response is much more variable.

        I would add: My experience is quite typical, from what the research says and other clinicians tell me.

  2. The research on both sides shows lack of clear perspective on both sides. One consistent piece of feedback I have received from the many hundreds of war veterans, rape victims and victims of natural disasters, that I have treated over 25 years of specialization is that TF-CBT causes acceleration of the PTSD and causes immense harm with NO positive benefits. Over 60% of PTSD victims self-resolve to below clinical levels (but continue with elevated anxiety) within 120 days of the trigger event, without intervention. In the 30+% of PTSD sufferers who end up with chronic PTSD continually focusing on the trigger events repeatedly re-traumatizes the client and does nothing to desensitize as is claimed.

    Removing flashbacks, intrusive thinking and other symptoms can only be done by treating the underlying emotional memory overwhelm, together with the long history of prior elevated anxiety (there is ALWAYS a minimum of 10 years of anxiety disorder in the background prior to the trigger events). This is partly emotional and partly biochemistry. Covering these bases to permanent resolution should never take more than 4 weeks, with the key flashbacks and intrusive thinking being stopped in the first session. This provides hope (which chronic and complex PTSD sufferers have invariably almost run out of after years of traditional treatments), and a basis for full resolution.

  3. I’ve just completed a residential stay of 6 months in a trauma clinic, for undiagnosed PTSD. I have tried many therapies in the past, including CBT, all unsuccessful. The treatment at the clinic was very effective, especially Somatic Experiencing, Internal Family Systems and EMDR. If you are really interested in effective trauma treatment, I suggest you study their programme….the clinic is called Khiron House. And if you want to discuss Trauma with any real understanding, I think bringing people into the discussion who have received effective treatment and are recovering from PTSD might be a useful thing to do.

  4. I found this article to be very interesting. I’m in the military and I have a close friend, who is also enlisted, that have PTSD. It’s hard to watch him get adjusted back to civilian life, because any little thing could set him off. He is currently receiving treatment, and he states that he is facing one demon at a time. I honestly don’t know if trauma-focused therapy is the best therapy for him, to relive those terrible moments of war over and over again. But he says that this is helping him adjust and come to terms with what has happened in his life.

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