What Works in the Treatment of Post Traumatic Stress Disorder? The Definitive Study

September 15, 2010 By scottdm 1 Comment

What works in the treatment of people with post-traumatic stress? The influential Cochrane Collaboration–an “independent network of people” whose self-professed mission is to help “healthcare providers, policy makers, patients, their advocates and carers, make well-informed decisions, concludes that, “non trauma-focused psychological treatments [do] not reduce PTSD symptoms as significantly…as individual trauma focused cognitive-behavioral therapy (TFCBT), eye movement desensitization and reprocessing, stress mamangement and group TFCBT.” The same conclusion was reached by the National Institute for Health and Clinical Excellence (or NICE) in the United Kingdom which has developed and disseminated practice guidelines that unequivocally state that , “all people with PTSD should be offered a course of trauma focused psychological treatment (TFCBT) or eye movement desensitization and reprocessing (EMDR).” And they mean all: adults and kids, young and old. Little room for left for interpretation here. No thinking is required. Like the old Nike ad, you should: “Just do it.”

Wait a minute though…what do the data say? Apparently, the NICE and Cochrane recommendations are not based on, well…the evidence–at least, that is, the latest meta-analytic research! Meta-analysis, you will recall, is a procedure for aggregating results from similar studies in order to test a hypothesis, such as, “are certain approaches for the treatment of post traumatic stress more effective than others?” A year ago, I blogged about the publication of a meta-analysis by Benish, Imel, & Wampold which clearly showed that there was no difference in outcome between treatments for PTSD and that the designation of some therapies as “trauma-focused” was devoid of empirical support, a fiction.

So, how to account for the differences? In a word, allegiance. Although written by scientists, so-called “scholarly” reviews of the literature and “consensus panel” opinions inevitably reflect the values, beliefs, and theoretical predilections of the authors. NICE guidelines, for example, read like a well planned advertising campaign for single psychotherapeutic modality: CBT. Indeed, the organization is quite explicit in it’s objective: “provide support for the local implementation of…appropriate levels of cognitive beheavioral therapy.” Astonishingly, no other approach is accorded the same level of support or endorsement despite robust evidence of the equivalence of outcomes among treatment approaches. Meanwhile, the review of the PTSD literature and treatment recommendations published by the Cochrane Collaboration has not been updated since 2007–a full two years following the publication of the Benish et al. (2008) meta-analysis–and that was penned by a prominent advocate of…CBT…Trauma-focused CBT.

As I blogged about back in January, researchers and prominent CBT proponents, published a critique of the Benish et al. (2008) meta-analysis in the March 2010 issue of Clinical Psychology Review (Vol. 30, No. 2, pages 269-76). Curiously, the authors chose not to replicate the Benish et al. study, but rather claim that bias, arbitrariness, lack of transparency, and poor judgement accounted for the findings. As I promised at the time, I’m making the response we wrote–which appeared in the most recent issue of Clinical Psychology Review—available here.

Of course, the most important finding of the Benish et al. (2008) and our later response (Wampold et al. 2010) is that mental health treatments work for people with post traumatic stress. Such a conclusion is unequivocal. At the same time, as we state in our response to the critique of Benish et al. (2008), “there is little evidence to support the conclusion…that one particular treatment for PTSD is superior to others or that some well defined ingredient is crucial to successful treatments of PTSD.” Saying otherwise, belies the evidence and diverts attention and scarce resources away from efforts likely to improve the quality and outcome of behavioral health services.

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Are all treatments approaches equally effective?

January 9, 2010 By scottdm Leave a Comment

Bruce Wampold, Ph.D.

Late yesterday, I blogged about a soon-to-be published article in Clinical Psychology Review in which the authors argue that the finding by Benish, Imel, & Wamppold (2008) of equivalence in outcomes among treatments for PTSD was due to, “bias, over-generalization, lack of transparency, and poor judgement.” Which interpretation of the evidence is correct? Are there “specific approaches for specific disorders” that are demonstrably more effective than others? Or does the available evidence show all approaches intended to be therapeutic to be equally effective?

History makes clear that science produces results in advance of understanding. Until the response to Ehlers, Bisson, Clark, Creamer, Pilling, Richards, Schnurr, Turner, and Yule becomes available, I wanted to remind people of three prior blog posts that review the evidence regarding differential efficacy of competing therapeutic approaches. The first (and I think most illuminating)–“The Debate of the Century“–appeared back in August. The post featured a link to a debate between Bruce Wampold and enthusiastic proponent of “empirically supported treatments,” Steve Hollon. Listen and then see if you agree with the large group of scientists and practitioners in attendance who thought–by a margin of 15:1–that Bruce carried the day.

The second post–Whoa Nellie!– commented on a 25 Million US$ research grant awarded by the US Department of Defense to study treatments for PTSD. Why does this make me think of “deep throat’s” admonition to, “follow the money!” Here you can read the study that is causing the uproar within the “specific treatments for specific disorders” gang.

Third, and finally, if you haven’t already read the post “Common versus Specific Factors and the Future of Psychotherapy,” I believe you’ll find the thorough review of the research done in response to an article by Siev and Chambless critical of the “dodo verdict” helpful.

History doesn’t repeat itself,

September 20, 2009 By scottdm 2 Comments

Image via Wikipedia

“History doesn’t repeat itself,” the celebrated American author, Mark Twain once observed, “but it does rhyme.” No better example of Twain’s wry comment than recurring claims about specifc therapeutic approaches. As any clinician knows, every year witnesses the introduction of new treatment models. Invariably, the developers and proponents claim superior effectivess of the approach over existing treatments. In the last decade or so, such claims, and the publication of randomized clinical trials, has enabled some to assume the designation of an “evidence-based practice” or “empirically supported treatment.” Training, continuing education, funding, and policy changes follow.

Without exception, in a few short years, other research appears showing the once widely heralded “advance” to be no more effective than what existed at the time. Few notice, however, as professional attention is once again captured by a “newer” and “more improved” treatment model. Studies conducted by my colleagues and I (downloadable from the “scholarly publications” are of my website), document this pattern with treatments for kids, alcohol abuse and dependence, and PTSD over the last 30 plus years.

As folks who’ve attended my recent workshops know, I’ve been using DBT as an example of approaches that have garnered significant professional attention (and funding) despite a relatively small number of studies (and participants) and no evidence of differential effectiveness. In any event, the American Journal of Psychiatry will soon publish, “A Randomized Trial of Dialectical Behavior Therapy versus General Psychiatric Management for Borderline Personality Disorder.”

As described by the authors, this study is “the largest clinical trial comparing dialectical behavior therapy and an active high-standard, coherent, and principled approach derived from APA guidelines and delivered by clinicians with expertise in treating borderline personality disorder.”

And what did these researchers find?

“Dialectical behavior therapy was not superior to general psychiatric management with both intent-to-treat and per-protocol analyses; the two were equally effective across a range of outcomes.” Interested readers can request a copy of the paper from the lead investigator, Shelley McMain at: Shelley_McMain@camh.net.

Below, readers can also find a set of slides summarizing and critiquing the current research on DBT. In reviewing the slides, ask yourself, “how could an approach based on such a limited and narrow sample of clients and no evidence of differential effectives achieved worldwide prominence?”

Of course, the results summarized here do not mean that there is nothing of value in the ideas and skills associated with DBT. Rather, it suggests that the field, including clinicians, researchers, and policy makers, needs to adopt a different approach when attempting to improve the process and outcome of behavioral health practices. Rather than continuously searching for the “specific treatment” for a “specific diagnosis,” research showing the general equivalence of competing therapeutic approaches indicates that emphasis needs to be placed on: (1) studying factors shared by all approaches that account for success; and (2) developing methods for helping clinicians identify what works for individual clients. This is, in fact, the mission of the International Center for Clinical Excellence: identifying the empirical evidence most likely to lead to superior outcomes in behavioral health.

Dbt Handouts 2009 from Scott Miller