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.