American Psychologist article about (not needing) exposure

[DynamicDidactic]

Rubenstein, A., Duek, O., Doran, J., & Harpaz-Rotem, I. (2024). To expose or not to expose: A comprehensive perspective on treatment for posttraumatic stress disorder. American Psychologist, 79(3), 331–343. APA PsycNet

Free to Read for the moment

Issue with commentaries

APA PsycNet

psycnet.apa.org

Who is writing a response? A SDN collaboration

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[PsyDr]

That is a pretty unique description of ACT and IPT. By those descriptions of ACT and IPT, imaginal exposure is also not exposure therapy.

 

[Sanman]

I agree, exposure is an outmoded paradigm for PTSD. The future is Prolonged Flooding Therapy!

On a serious note, my psychotherapy approach has been reliably successful and it isn't based in exposure (although it usually is incorporated)...but that is in a context of having a very effective pharmacologic approach.

Don't give the politicians ideas. I can already picture the salivation about the cure for PTSD being more war. Like hair of the dog...

 

[MCParent]

Don't give the politicians ideas. I can already the salivation about the cure for PTSD being more war. Like hair of the dog...

Can’t have a post traumatic disorder if the trauma never ends!

 

[EnPsychlopedia]

I know that @cara susanna has strong opinions about this because I tagged her in a Reddit post about it and she had some words haha

 

[MCParent]

OT but we need a moratorium on “cute title: real title” journal article titles.

 

[ClinicalABA]

OT but we need a moratorium on “cute title: real title” journal article titles.

Right?? It's scientific prose, not a blog post

 

[PsyDr]

Right?? It's scientific prose, not a blog post

Ehhhhhh. I would expect a scientific article to have statistics like efficacy rates, effect sizes, or even NNT. This is just a thinly veiled opinion.

 

[WisNeuro]

Ehhhhhh. I would expect a scientific article to have statistics like efficacy rates, effect sizes, or even NNT. This is just a thinly veiled opinion.

This is pretty much all The American Psychologist publishes, really.

 

[ClinicalABA]

Ehhhhhh. I would expect a scientific article to have statistics like efficacy rates, effect sizes, or even NNT. This is just a thinly veiled opinion.

fixed that for you.

 

[AcronymAllergy]

Is this where we start having the debate that this is the authors' own personal truth, so we can't question it, and really that there's no such thing as objective truth anyway?

 

[Sanman]

Reading the article, I see a lot pointless pontificating over mechanisms of action rather than actual elements involved in the treatment (EMDR and ACT propose to work differently than PE and are also efficacious...though they both utilize in vivo exposure). The only useful discussion, IMO, is about the variability in PTSD symptoms and whether non-exposure treatments can be efficacious in patients who suffer more anhedonia type sx and less re-experiencing and nightmares.

 

[WisNeuro]

Reading the article, I see a lot pointless pontificating over mechanisms of action rather than actual elements involved in the treatment (EMDR and ACT propose to work differently than PE and are also efficacious...though they both utilize in vivo exposure). The only useful discussion, IMO, is about the variability in PTSD symptoms and whether non-exposure treatments can be efficacious in patients who suffer more anhedonia type sx and less re-experiencing and nightmares.

People who hate on PE/CPT have some weird projection going on. I spent a good amount of time in the PTSD treatment world and I never recall anyone saying that exposure is necessary, or that PE/CPT are the "only" treatments for PTSD. Seems like an entirely fabricated argument for the pseudoscience hucksters to peddle their wares.

 

[ClinicalABA]

Reading the article, I see a lot pointless pontificating over mechanisms of action rather than actual elements involved in the treatment (EMDR and ACT propose to work differently than PE and are also efficacious...though they both utilize in vivo exposure). The only useful discussion, IMO, is about the variability in PTSD symptoms and whether non-exposure treatments can be efficacious in patients who suffer more anhedonia type sx and less re-experiencing and nightmares.

I'd agree. It seems like the ultimate conclusion is that exposure is not necessary for everyone. That seems rather intuitive and non-interesting to me. Their argument is also to a great extent based on the position that there's good evidence for concluding that there is an overall negligible effect size of therapy type as relate to therapy outcome. However, the provide only four references for this. One of them (Luborsky et al. is older than me and came out at a time when Wolpe-ian systematic desensitization or flooding were cutting edge. Another (Wampold et al. seems to be a response to criticism of a previous meta-analysis). Another (Shea et al., is a descriptive review of treatments. While the forth (Lenz et al.) is an actual meta anaylsis, it doesn't provide unequivocal support for their thesis. Overall, not the strongest foundation.

 

[Shiori]

I was curious, and asked Claude.ai to present counterarguments:

Some potential counterpoints or arguments against the points made in this review article include:

1. Numerous high-quality randomized controlled trials have demonstrated the efficacy of prolonged exposure therapy as a front-line treatment for PTSD. Dismissing this large evidence base in favor of other less well-established treatments could be premature.
2. While dropout rates are a concern, exposure therapies like PE still outperform other treatments and waitlist controls in symptom reduction for treatment completers. Efforts should focus on enhancing engagement rather than abandoning an effective treatment.
3. The proposed mechanisms like reconsolidation and autobiographical integration are speculative, while inhibitory learning through extinction is a more established mechanism supported by the animal literature.
4. Non-trauma-focused therapies may facilitate some self-exposure, but do not directly target the proposed mechanisms of change in PTSD (inhibiting fear conditioning). Their efficacy may be limited compared to trauma-focused methods.
5. Common factors like therapeutic alliance likely augment but do not fully account for the specific effects of exposure protocols on PTSD symptoms.
6. While complex/comorbid presentations may benefit from non-exposure approaches, for straightforward PTSD cases, exposure should remain the frontline treatment given its demonstrated efficacy.
7. Overly broadening the conceptualization of PTSD treatment could lead to diffuse, non-specific approaches lacking the focused mechanisms and techniques that make exposure therapies effective.

In essence, the counterarguments would emphasize the strong existing evidence base for exposure therapies, the speculative nature of proposed alternative mechanisms, and the risk of prematurely abandoning an effective frontline treatment paradigm that still likely needs refinement rather than replacement.

Not bad.

 

[futureapppsy2]

Saying that exposure in ACT isn't really exposure because it conceptualizes the outcomes slightly differently is... a choice.

 

[futureapppsy2]

This is pretty much all The American Psychologist publishes, really.

I had the weirdest experience with them as an author--we submitted a paper to a special issue after a successful LOI, got a R&R, did the recommended revisions, and the revision... got desk rejected? (We published the paper elsewhere, so eh).

 

[cara susanna]

In addition to what others have mentioned:
1) the citations don't really support the authors' assertion that exposure doesn't work - one article even says that PE did the best compared to other treatments! I also personally know the author of an article they leaned on a lot, and I know that person would not agree with their conclusions about PE. I'm actually going to ask when I'm back in the office.
2) Defining failure to achieve remission of diagnosis as a treatment failure is... a choice. Honestly, almost 50% achieving loss of diagnosis is pretty darn good. They didn't look at any other outcomes, even though the PCL-5 is a continuous measure and we could look at clinically significant improvement. AND we have evidence that people continue to improve even after PE is completed, so they might have done even better after the study took its last measurement.
3) It KILLS me that they cite VA clinicians' opinions of exposure as "too aversive" or "ineffective" for our "complex" population (lmao) as evidence. Those clinicians are wrong, and their ignorance should not be used as an argument against using PE.
4) There ARE promising non-exposure based treatments, and CPT is not exposure based but works very well. However, imo this article doesn't do them any favors
5) From my understanding, PCT has done surprisingly well as a control condition in RCTs, but that doesn't mean it's an effective treatment on its own (hence why it wasn't included in the 2024 CPG recommended treatments tier - HOWEVER, if you remember, Kate Chard and others who are by no means opposed to trauma processing therapies have criticized the updated CPG for being too stringent).
6) Therapy dropout rates are high in general, and there is a burgeoning area of work that is suggesting that some dropout may be early completion - basically, dropout may not always be a negative outcome. APA PsycNet Studies also have overwhelmingly showed that PE dropout is related more to therapy expectations and scheduling, not inability to tolerate the therapy.

 

[clausewitz2]

I was curious, and asked Claude.ai to present counterarguments:

Some potential counterpoints or arguments against the points made in this review article include:

1. Numerous high-quality randomized controlled trials have demonstrated the efficacy of prolonged exposure therapy as a front-line treatment for PTSD. Dismissing this large evidence base in favor of other less well-established treatments could be premature.
2. While dropout rates are a concern, exposure therapies like PE still outperform other treatments and waitlist controls in symptom reduction for treatment completers. Efforts should focus on enhancing engagement rather than abandoning an effective treatment.
3. The proposed mechanisms like reconsolidation and autobiographical integration are speculative, while inhibitory learning through extinction is a more established mechanism supported by the animal literature.
4. Non-trauma-focused therapies may facilitate some self-exposure, but do not directly target the proposed mechanisms of change in PTSD (inhibiting fear conditioning). Their efficacy may be limited compared to trauma-focused methods.
5. Common factors like therapeutic alliance likely augment but do not fully account for the specific effects of exposure protocols on PTSD symptoms.
6. While complex/comorbid presentations may benefit from non-exposure approaches, for straightforward PTSD cases, exposure should remain the frontline treatment given its demonstrated efficacy.
7. Overly broadening the conceptualization of PTSD treatment could lead to diffuse, non-specific approaches lacking the focused mechanisms and techniques that make exposure therapies effective.

In essence, the counterarguments would emphasize the strong existing evidence base for exposure therapies, the speculative nature of proposed alternative mechanisms, and the risk of prematurely abandoning an effective frontline treatment paradigm that still likely needs refinement rather than replacement.

Not bad.

Was that Opus or Sonnet?

I have access to Gemini Pro 1.5 and asked it to do the same thing as a well-respected trauma expert but with a skeptical and pugnacious tone. This seems SDN-levels of salty:

A Skeptic's Take on "To Expose or Not to Expose":​

This paper attempts to dismantle the "gold standard" status of exposure therapy for PTSD, but it falls short of delivering a knockout punch. While it dances around valid concerns, it ultimately throws weak jabs instead of landing decisive blows. Let's dissect its flawed logic:

Overstating the Problem:

• Cherry-Picking Data: The paper highlights high dropout rates and incomplete remission, conveniently ignoring the substantial body of evidence demonstrating exposure therapy's effectiveness in reducing PTSD symptoms and improving quality of life for many individuals.
• Ignoring Long-Term Gains: Focusing solely on immediate post-treatment outcomes paints an incomplete picture. Exposure therapy's benefits often unfold over time, leading to lasting reductions in PTSD symptoms and improved functioning.

Misunderstanding Mechanisms:

• Downplaying Extinction: The paper conveniently dismisses extinction learning despite its well-established role in fear reduction. Repeated exposure to feared stimuli, without the feared consequences, demonstrably weakens the fear response.
• Discrediting Habituation: While the paper nitpicks at the nuances of habituation and its relation to outcome, it overlooks its contribution to distress tolerance and reduced avoidance, which are crucial for PTSD recovery.
• Obsessing Over Reconsolidation: The paper fixates on the shiny new toy of reconsolidation, a complex and not fully understood process, while neglecting the well-established mechanisms of extinction and cognitive change that underpin exposure therapy's effectiveness.

False Dichotomies:

• Trauma-Focused vs. Everything Else: The paper creates a false dichotomy between trauma-focused and non-trauma-focused therapies, implying that only the latter are holistic. This ignores the reality that trauma-focused therapies can be tailored to individual needs and often incorporate elements addressing broader life challenges.
• Exposure as a Therapist Technique: By focusing on therapist-directed exposure, the paper conveniently ignores the potential for spontaneous exposure outside of therapy, which can be facilitated by various therapeutic approaches.

Ignoring the Bigger Picture:

• Exposure Therapy Variations: The paper's narrow focus on PE ignores the broader spectrum of exposure therapy approaches that may be more acceptable and effective for certain individuals.
• Combined Treatments: The paper overlooks the potential of combining exposure therapy with other evidence-based approaches, such as medication or mindfulness, to optimize outcomes and address specific needs.

In conclusion, this paper throws punches in the air, failing to land a convincing argument against exposure therapy's position as a leading treatment for PTSD. While acknowledging the need for individualized treatment and ongoing research, let's not discard a well-established and effective approach based on theoretical nitpicking and a selective presentation of evidence.

 

[Sanman]

It is always so funny to me to that these arguments occur regarding exposure therapy. Every argument against it (it is difficult, it does not always cure you, etc.) can also be made for radiation and chemotherapy for cancer. Yet, there is more resistance to this than there is to those cancer treatments.

 

[cara susanna]

Was that Opus or Sonnet?

I have access to Gemini Pro 1.5 and asked it to do the same thing as a well-respected trauma expert but with a skeptical and pugnacious tome. This seems SDN-levels of salty:

A Skeptic's Take on "To Expose or Not to Expose":​

This paper attempts to dismantle the "gold standard" status of exposure therapy for PTSD, but it falls short of delivering a knockout punch. While it dances around valid concerns, it ultimately throws weak jabs instead of landing decisive blows. Let's dissect its flawed logic:

Overstating the Problem:

• Cherry-Picking Data: The paper highlights high dropout rates and incomplete remission, conveniently ignoring the substantial body of evidence demonstrating exposure therapy's effectiveness in reducing PTSD symptoms and improving quality of life for many individuals.
• Ignoring Long-Term Gains: Focusing solely on immediate post-treatment outcomes paints an incomplete picture. Exposure therapy's benefits often unfold over time, leading to lasting reductions in PTSD symptoms and improved functioning.

Misunderstanding Mechanisms:

• Downplaying Extinction: The paper conveniently dismisses extinction learning despite its well-established role in fear reduction. Repeated exposure to feared stimuli, without the feared consequences, demonstrably weakens the fear response.
• Discrediting Habituation: While the paper nitpicks at the nuances of habituation and its relation to outcome, it overlooks its contribution to distress tolerance and reduced avoidance, which are crucial for PTSD recovery.
• Obsessing Over Reconsolidation: The paper fixates on the shiny new toy of reconsolidation, a complex and not fully understood process, while neglecting the well-established mechanisms of extinction and cognitive change that underpin exposure therapy's effectiveness.

False Dichotomies:

• Trauma-Focused vs. Everything Else: The paper creates a false dichotomy between trauma-focused and non-trauma-focused therapies, implying that only the latter are holistic. This ignores the reality that trauma-focused therapies can be tailored to individual needs and often incorporate elements addressing broader life challenges.
• Exposure as a Therapist Technique: By focusing on therapist-directed exposure, the paper conveniently ignores the potential for spontaneous exposure outside of therapy, which can be facilitated by various therapeutic approaches.

Ignoring the Bigger Picture:

• Exposure Therapy Variations: The paper's narrow focus on PE ignores the broader spectrum of exposure therapy approaches that may be more acceptable and effective for certain individuals.
• Combined Treatments: The paper overlooks the potential of combining exposure therapy with other evidence-based approaches, such as medication or mindfulness, to optimize outcomes and address specific needs.

In conclusion, this paper throws punches in the air, failing to land a convincing argument against exposure therapy's position as a leading treatment for PTSD. While acknowledging the need for individualized treatment and ongoing research, let's not discard a well-established and effective approach based on theoretical nitpicking and a selective presentation of evidence.

Ah, yes, the AI brings up some good points as well (and I also love the snarky tone). I forgot to mention that intent to treat analyses account for dropout, and still show that PE is effective.

 

[Shiori]

I just used Sonnet. ChatGPT is blocked here, or I'd use ChatGPT Plus. The snarky tone is fabulous. I gave Claude a very basic prompt. Next time, I should get fancy!

 

[DynamicDidactic]

damn these AI are good. Can we have AI write a rebuttal and submit it?

 

[cara susanna]

Apparently there were TWO responses to this paper, as well as a rebuttal from the original paper's author

 

[EnPsychlopedia]

Apparently there were TWO responses to this paper, as well as a rebuttal from the original paper's author

Wait...does that Najavits paper seriously suggest adding transcendental meditation to the list of evidence-based trauma treatments?

 

[cara susanna]

I didn't have time to read the responses before posting them, and I see now that they are SUPPORTIVE of the original article.

 

[EnPsychlopedia]

I didn't have time to read the responses before posting them, and I see now that they are SUPPORTIVE of the original article.

Yeah I did a quick glance at them and they are very much simpering for the original contribution haha

 

[cara susanna]

Wouldn't you want, like, some variety in opinions? I'm so confused by this.

 

[Sanman]

Apparently there were TWO responses to this paper, as well as a rebuttal from the original paper's author

These articles seem best summed up as "Don't put me in a box, man!"

At the end of the day, I do agree that exposure therapy is not the ONLY thing that can benefit a person with PTSD given that clinical presentations can be complex and treatments need to address multiple factors. I also agree that clinical decision making and clinical skills matter more generally. That said, I find some of their suggestions both puzzling and ridiculous. They mention that exposure therapy is time consuming, costly, and requires additional training. Yet, they advocate for individualized analysis of cases and increased time for rapport building. Good clinical and treatment planning skills and rapport building are not costly? I agree with some of the sentiments, but they take it too far. At the end of the day, there need to be guidelines of some sort because everyone does not have the time for thoughtful decision making in every case and insurance would never allow that. That said, of course non-exposure therapies and other treatment can be helpful to fairly debilitated individuals that need a variety of things to enter remission (coping skills, social support, problem solving skills, etc.) I'm not sure why that needs to be argued. Not sure that any insurance company is going to go with the idea that anything can be helpful and the clinician has free reign to as they please. I definitely don't see anyone covering race based trauma. However, if we want to classify all minorities as having PTSD, that sounds like a nice way to increase revenue generation.

 

[MCParent]

Wouldn't you want, like, some variety in opinions? I'm so confused by this.

I see you’re new to the APA.