APA PTSD Treatment Guidelines

[cara susanna]

Just wanted to start a thread in case anyone else is following the controversy regarding APA's PTSD practice guidelines. I personally am extremely frustrated, so I wanted to vent a little here. I don't know how other people feel, but I personally believe that every issue that has been raised about the guidelines has been addressed more than sufficiently by members of the task force, and that this discussion is perpetuating a lot of harmful myths and ideas about PTSD and its treatment that aren't backed by research.

---

Members don't see this ad.

 

[psych1420]

Just wanted to start a thread in case anyone else is following the controversy regarding APA's PTSD practice guidelines. I personally am extremely frustrated, so I wanted to vent a little here. I don't know how other people feel, but I personally believe that every issue that has been raised about the guidelines has been addressed more than sufficiently by members of the task force, and that this discussion is perpetuating a lot of harmful myths and ideas about PTSD and its treatment that aren't backed by research.

Care to shed some light on this? I'm curious but not sure what controversy you're referring to?

 

[cara susanna]

Basically, APA released some guidelines for treating PTSD and a lot of the field has reacted very negatively towards them, saying things like they over-emphasize RCTs, don't consider comorbidities, don't address complex trauma, that these recommended treatments can cause harm, etc. I've mostly seen it in listservs that I can't quote here, but I can link you towards this blog article in Div 35 discussing their issues with the guidelines.

APA Division 35 Townhall Blog: Guidelines for the Treatment of PTSD

Anyway, as a result of a bunch of people have created and signed a petition asking APA to reconsider these guidelines. Another petition has been circulating urging APA to support them. It's a big mess, haha.

Edit: You can see the petition opposing the guidelines at the link, but here is a direct one as well: Sign Petition: Protect PTSD Treatments That Work!

 

[WisNeuro]

Are the "complex PTSD" people still trying to claim that it's a distinct entity, and not just someone with BPD who happened to have a traumatic experience?

 

[cara susanna]

I believe so, yes. And also that CPT or PE doesn't work with complex trauma.

 

[WisNeuro]

I believe so, yes. And also that CPT or PE doesn't work with complex trauma.

But EMDR and psychoanalysis lasting 5+ years do work?>

 

[foreverbull]

Per an email I recieved on a listserv (take a look at the concerns raised):

"Due to the exclusive reliance on RCT outcomes in formulating the guideline, other legitimate research findings crucially and commonly supporting additional forms of PTSD treatment were not considered in the assignment of "strong" recommendations.

• The studies upon which the guideline is based included only a subset of patients--those without comorbidities-- and therefore the findings of these studies may or, more likely, may not apply to most patients seeking PTSD treatment. Although some co-morbidities have been studied, many have not, especially within the limited scope of research considered.

• The APA is recommending specific treatments for those patients anyway, despite the lack of data to support such generalization, in contrast to the procedures for the ethical management and communication of research findings that are considered standard practice.

• The APA is also recommending specific treatments for so-called complex patients, such as those with psychosis, homelessness, incarceration histories, cognitive impairment, etc., who have consistently been excluded from PTSD trials, despite the lack of a scientific basis for these recommendations.

• The studies considered were unable adequately to evaluate harms and burdens associated with the recommended treatments, which may carry significant unknown risks to consumers, particularly consumers with comorbid conditions and others excluded from the populations studied in formulating the guideline.

• The guideline endorses types of treatment from which there is an unusually high attrition rate without endorsing alternatives for those who were not served by the treatments the guideline supports. Attrition rates were also not meaningfully factored into the strength of the recommendations.

• It can be reasonably expected that the dissemination of this guideline may be used to place restrictions upon psychologists' scope of practice and insurance reimbursements to patients and practitioners. Such restrictions may result in harm to patients by limiting their awareness of or access to forms of treatment that are shown to be at least as beneficial as the forms of treatment promoted in their guideline. (Blue Cross Blue Shield of Illinois has already adopted this guideline, no doubt the first among many insurers.) Practically speaking, the promotion of the guideline will likely impede patients' informed choice as to the sorts of treatments they undergo.

• The APA's vote on the guideline was based upon the provision that a professional practice guideline would be issued along with the treatment guideline in order to give indications as to how the guideline might be applied in real-world situations; it was not.

• The APA's rationale for not considering other forms of supportive data – the need to adopt the Institute of Medicine's (IoM) standards for evidence based treatment -- is disingenuous; the only other professional organization in the country that has issued treatment guidelines, the American Psychiatric Association, has used the IoM standards successfully to formulate less restrictive guidelines without the consequences APA claimed its method was necessary to avoid. The result is that psychiatrists are not restricted from providing other multiple forms of treatment in the way psychologists are.

• The process through which the guideline was developed stands in contrast to the standards for ethical research procedures for which the APA has been a consistent advocate in other contexts, and the content of the guideline violates the APA's own concurrently-issued guideline for providing multi-culturally sensitive forms of therapy.

On the basis of these and many other concerns, we request that State and Division APA organizations advocate for, and that the APA Counsil of Representatives implement, the following remedies:

• Place a moratorium upon the issuance of healthcare practice guidelines, including the additional guidelines under development for the treatment of other disorders, until a more balanced, responsible, and responsive general guidelines process can be developed for evaluating treatment recommendations. This would include extensive development of an overarching policy that specifies the relationship between treatment and clinical practice guidelines.

• Create a CoR Task Force to review and make recommendations to Council regarding the APA's general policy regarding the formulation of healthcare practice guidelines. Ensure a task force composition that sufficiently includes diverse theoretical and practice orientations, precludes conflicts of interest, and assures consistency with other guidelines and standards of practice, for example those that appear in the APA's multicultural guideline. The creation of such a CoR Task Force should be initiated at the March, 2018 Council meeting.

• Immediately issue and prominently display a supplementary "black box" statement to accompany the PTSD guideline that details the potential harm to patients that may be caused by using the guidelines to limit treatment options, promote the recommended treatments for populations not included in the RCTs considered (e.g. comorbid conditions), or mis-represent the therapy process and its justifications.

• State explicitly that the PTSD guideline is not to be used by insurance companies and other providers for purposes of determining medical necessity, and is not to be taken as a standard of care.

• Review, revise, and reissue the guideline, after a full and considered process consistent with APA's ethical standards, in a way that clearly defines its role as a resource for clinicians, who retain the final judgment of appropriate treatment for any individual case, rather than as a treatment standard to be adopted and enforced by insurance companies

• Cease to market and promote the current guideline in ways that ignore the disclaimers, caveats, and limitations that are stated in the guideline itself. All future marketing material must include these limitations, or must cease altogether."

 

[Therapist4Chnge]

Are the "complex PTSD" people still trying to claim that it's a distinct entity, and not just someone with BPD who happened to have a traumatic experience?

That’s been my experience too. Unfortunately there are more than a few clinicians who actually encourage this “new” diagnosis.

They typically bomb both Psych & Neuropsych evals....go figure.

 

[cara susanna]

Thanks for posting the specifics, @foreverbull Like I said, I personally think that a lot of those objections aren't actually true and have been sufficiently refuted by those who helped craft the guidelines.

 

[Justanothergrad]

I take some issue with the guidelines. I don't see a reason why doing so is harmful. I want to be clear, however. I think that there is a lot to like about strong empirical science and I'm supportive of efforts to improve our utilization of it in clinical practice. This is part of why I dislike the guidelines. They're premature and I view them as too concretely written despite their shortcomings. I'll highlight a few of the reasons I object to the guidelines.

--You are unlikely to convince me that guidelines which support EMDR are as empirically based as they make themselves out to be. They currently put it on nearly equal footing as CPT/PE/CBT (and expect to be recommended with equal strength soon). There are a lot of reasons to be skeptical of the research on EMDR and those are under-reported in the guidelines.
--Not only that, the RCTs supporting PE/CPT are generally done in very different clinical contexts than what they are typically used in. CPT uses a residential program with a lot more supports, greater HW engagement, and a far smaller dropout. This makes a fundamentally different treatment if you want to say the manual for it is a standard guideline. The exclusionary criteria for the studies they have used to make these guideline decisions also concern me.
--I'm yet to see a sufficient state of research in RCT to offer as broadly conclusive guidance as is included in these guidelines. If a majority of the effect sizes for these studies are compared to wait-list control, thats not sufficient to recommend one therapy over another. That doesn't answer that question.

At this point, its probably easier to identify therapies that cause harm/therapies to avoid than to list off which are the hands-down, no questions asked, best.

A link to the guidelines: https://www.apa.org/ptsd-guideline/ptsd.pdf

 

[DSMX]

Oh man, where to begin. Where... to ... begin.

Well first, thank you @cara susanna for starting this thread.

I find it laughable that the description of the petition doesn't at all contain the therapies that they think should have been considered. Instead we just get this line: "the problem is that this guideline did not take into account the evidence for intensive 'talk therapy' and for other treatments that have helped countless thousands of traumatized people get back on their feet and change their lives."

Uhm, okay. Well then cite those talk therapies which should have been considered. Tell us their names. Show us the evidence of their effectiveness that you state exists.

Well since they didn't lay it out for the reader of the petition, I tried to find it for them. The link on the bottom of the petition (where one should go to "for more detail and supporting documents") takes you to a tinyurl which directs to a dropbox with two documents. TWO. Neither of which are scientific articles. In fact, one of the two documents which are supposed to provide "more detail," and "support" their stance is the EXACT content of the petition itself. The other document is a letter from the the psychotherapy "action" network to the Illinois state psychology association. We FINALLY see some published articles cited in that letter. Yet, still not a single citation for research on a therapy that they felt should have been included.

For those who are interested, here are the VA/DOD PTSD treatment guidelines that were updated in November, 2017: Management of Posttraumatic Stress Disorder and Acute Stress Reaction 2017 - VA/DoD Clinical Practice Guidelines You'll see similar PTSD psychotherapy recommendations.

Overall, I find it so hard to have any confidence in these folks who claim to take issue with these, or any, research-informed PTSD treatment guidelines. There is a plethora of research showing the effectiveness of cognitive behaviorally based treatments for PTSD. Is that research always perfect? No. But if you believe a treatment you are doing is more effective than what is currently being recommended, apply for a grant and conduct a research study on it. Show us its effectiveness rather than just make a claim of it in a petition.

 

[foreverbull]

Thanks for posting the specifics, @foreverbull Like I said, I personally think that a lot of those objections aren't actually true and have been sufficiently refuted by those who helped craft the guidelines.

My takeaway from all of the information is that the main concerns are:

1. no longterm or non-RCT research was included in the findings
2. RCTs have limited generalizability, yet APA was willing to endorse RCT-based treatments for all individuals (the findings ignore cultural factors, rely on a one-size-fits-all approach, and ignore comorbidity issues)
4. this can be used to restrict practice to APA-endorsed treatments via insurance company endorsement/control
5. attrition rates were not adequately considered when endorsing the actual use of these treatments
6. psychologists could eventually be punished via state boards/complaints if practicing other treatments for PTSD with research support that do not have APA endorsement (when taken to the extreme)

Per APA's guideline: "In addition to these strengths, the guideline also has some limitations. Gaps in the
current empirical literature regarding treatment comparisons, evaluation of moderators of treatment effects, inclusion of participants with comorbidities, measurement of potential side effects and harms, and assessment of important outcomes and the timing of their assessment all need to be addressed to answer important clinical questions. Additionally, methodological improvements that minimize attrition/dropout, decrease missing data and ensure sufficient power will improve the quality of the findings and hence the possible conclusions that can be drawn. Finally, the panel did not have data on which to make recommendations for some treatments in use because they arise from traditions with non-RCT research practices or the quality of the research base has not been subjected to the level of critical appraisal of
systematic review."

These are serious limitations that should be considered, but I don't disagree that the endorsed treatments are effective for certain clients. I was trained in PE, and it is effective for those who can tolerate it. These treatments that are endorsed are fine in general as different tools for use with PTSD, but aren't for everyone. Not all folks can tolerate PE per the standard protocol. What would be the alternative in APA's terms? CPT, CBT, Brief Psychodynamic, EMDR, Relaxation and pharmacological treatments only?

Interpersonal therapy has research support, but didn't make the cut because we need more studies in this area (we have a few supporting its use, but we need more). Mindfulness may also decrease PTSD symptoms, but we don't have enough research yet. I'm sure there are other approaches as well. If APA endorses a few and ignores alternative treatment possibilities, will we get to continue to explore/research these and other treatments or will they fall by the wayside and be labeled "unscientific" or "unsupported" because no one wants to research them now to see if they are just as effective?

To me, the guidelines highlight the issue of fads in research, that is to say, a flurry of research will come out for a particular treatment, and other promising treatments may get ignored or not researched because they aren't popular.

Absolutely use the methods that have a solid body of support, AND lets research others and not fully endorse treatments until we have broad research on a wide range of treatments for PTSD rather than just a few. RCTs are our "gold standard," but I'd like to see additional types of research included as well as RCTs for other treatments.

 

[DSMX]

not fully endorse some until we have broad research on a wide range of treatments for PTSD rather than just a few

We have PTSD research on:

CBT
CPT
PE
EMDR
STAIR
PCT
Written Exposure
ACT
DBT

Those aren't all equally effective to treat PTSD. However, is that not broad enough yet? If not, how many more is needed to fulfill your criteria for "broad" and "wide range"? So according to you, before we set any guidelines that could help providers direct patients to a treatment that is shown to be effective in treating PTSD, we should just let it be the wild west and let any and all treatments for PTSD anyone can imagine suffice?

 

[foreverbull]

However, is that not broad enough yet? If not, how many more is needed to fulfill your criteria for "broad" and "wide range"? So according to you, before we set any guidelines that could help providers direct patients to a treatment that is shown to be effective in treating PTSD, we should just let it be the wild west and let any and all treatments for PTSD anyone can imagine suffice?

You'll note that I listed 2 treatments you didn't mention that have some research support but need more studies. APA acknowledged that they left out treatments due to the treatment lacking RCTs.

You'll also note that I said the APA-endorsed treatments are effective and we can use them carefully (I'm trained in PE, as I mentioned), but let's also address the several limitations that APA acknowledged. Read the "Generalizability" section of the APA guidelines (76-80) for more detailed information about the issues with generalizing treatments to everyone (ethnic minorities, etc.).

I don't think we should be like the "Wild West" in treating folks with PTSD, so no need to go straight to the worst case scenario. I don't think PTSD is a disorder just any therapist should be treating in the first place without training/supervision.

 

[AcronymAllergy]

Caveat: I'm no PTSD expert. But skimming the APA's recommendations, as written, I don't know that I have a problem with them. Perhaps couching some of the wording used to include more "when deemed clinically appropriate" verbiage, or something similar. We know the limitations of existing RCTs, but I believe there's enough evidence to support recommendation of certain treatments, and to suggest that these may be the best bet as first-line interventions (again, pending clinical judgment). If future evidence shows otherwise or supports additional treatments, adjustments can always be made. On the flip side, I once spoke with a person who said that they didn't "believe" in exposure therapy for PTSD; these are the types of situations that treatment guidelines are, in part, designed to help us avoid/combat.

 

[foreverbull]

If future evidence shows otherwise or supports additional treatments, adjustments can always be made. On the flip side, I once spoke with a person who said that they didn't "believe" in exposure therapy for PTSD; these are the types of situations that treatment guidelines are, in part, designed to help us avoid/combat.

Yes, I would agree with this as well. I just don't want promising treatments that show research support for PTSD treatment but may not be manualized or manualized at present to be completely left out of the conversation in the future.

I would hope that folks can recognize that exposure-based therapies are supported by research, but as you say, using clinical judgment about when it may or may not be indicated. We don't know much about their use with ethnic minorities at present, so I think that's something we really need to research further.

 

[DSMX]

You'll note that I listed 2 treatments you didn't mention that have some research support but need more studies. APA acknowledged that they left out treatments due to the treatment lacking RCTs.

You'll also note that I said the APA-endorsed treatments are effective and we can use them carefully (I'm trained in PE, as I mentioned), but let's also address the several limitations that APA acknowledged. Read the "Generalizability" section of the APA guidelines (76-80) for more detailed information about the issues with generalizing treatments to everyone (ethnic minorities, etc.).

I don't think we should be like the "Wild West" in treating folks with PTSD, so no need to go straight to the worst case scenario. I don't think PTSD is a disorder just any therapist should be treating in the first place without training/supervision.

APA also left out treatments like PCT and STAIR, which have research showing their effectiveness in treating PTSD. So what's being done? Researchers behind those treatments are conducting more RCTs, to eventually prove their effectiveness at a larger scale. I'm aware of RCTs currently being done with IPT too.

So, until the research shows their effectiveness, they will not be included in the guidelines. We have to start somewhere (god, I feel like Hamilton right now). These guidelines are a start. The VA/DOD guidelines have been through at least one revision already.

And of course nobody should conduct these treatments without training. Nobody is saying that. The guidelines will help providers (across all disciplines) who are not aware of the front-line PTSD treatments, direct their patient to those treatments.

 

[DSMX]

. We know the limitations of existing RCTs, but I believe there's enough evidence to support recommendation of certain treatments, and to suggest that these may be the best bet as first-line interventions (again, pending clinical judgment). If future evidence shows otherwise or supports additional treatments, adjustments can always be made.

Exactly. This is just the APA's first version of PTSD guidelines. They will continue to evolve as the research evolves.

 

[Justanothergrad]

Exactly. This is just the APA's first version of PTSD guidelines. They will continue to evolve as the research evolves.

I'm fine with a first version of treatment guidelines which summarize the state of the literature. I expect that we will see more of these in the future. But in creating a first version, there needs to be some explicit description of the methodology so we can help contextualize recommendations and understand differences.
- What therapies did they evaluate in their review?
- What studies did they review for each of those studies?
- How many studies are required to garner support (e.g., Div 12 versus Div 17 guidelines)
- Of those reviewed, which ones were used to formulate their conclusion?
- What exact inclusion/exclusion did they use?
- How did they weight the importance of their included studies?
- What exact review criteria led them to differentiate strong support from moderate support?
etc.

These questions are all basic ones required for reporting of any systematic review/meta-analysis. I don't see a reason that it should be acceptable not to include them explicitly here. While probably not best fitted to the report itself, this seems like the sort of thing that should be available for clinicians and researchers to review to evaluate the decision making process. If I can't describe what they did to another committee to replicate it, then their Method section needs work. Its beyond odd to me that a scientific summary of research that professes to identify the future of supported treatments (as we know it now) should exclude this critical information.

 

[DSMX]

I'm fine with a first version of treatment guidelines which summarize the state of the literature. I expect that we will see more of these in the future. But in creating a first version, there needs to be some explicit description of the methodology so we can help contextualize recommendations and understand differences.
- What therapies did they evaluate in their review?
- What studies did they review for each of those studies?
- How many studies are required to garner support (e.g., Div 12 versus Div 17 guidelines)
- Of those reviewed, which ones were used to formulate their conclusion?
- What exact inclusion/exclusion did they use?
- How did they weight the importance of their included studies?
- What exact review criteria led them to differentiate strong support from moderate support?
etc.

These questions are all basic ones required for reporting of any systematic review/meta-analysis. I don't see a reason that it should be acceptable not to include them explicitly here. While probably not best fitted to the report itself, this seems like the sort of thing that should be available for clinicians and researchers to review to evaluate the decision making process. If I can't describe what they did to another committee to replicate it, then their Method section needs work. Its beyond odd to me that a scientific summary of research that professes to identify the future of supported treatments (as we know it now) should exclude this critical information.

I'm not sure it's been posted to this thread yet, but if one goes to this link: Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD). And click on "appendices," you'll a 556 page document with their methodology and rationale.

Meanwhile the petition has two documents. One is an exact replication of their protest, and the other is a letter.

 

[Justanothergrad]

I had missed that. I'll go through and hopefully it addresses that part of my concerns sufficiently.

 

[DSMX]

I had missed that. I'll go through and hopefully it addresses that part of my concerns sufficiently.

No problem. That's what threads like this are for -- so that we can inform each other. I'm pretty sure that document answers all of your questions. Some may still have disagreements about those answers though.

 

[DailyJoy]

Are the "complex PTSD" people still trying to claim that it's a distinct entity, and not just someone with BPD who happened to have a traumatic experience?

I'm in grad school and have become increasing interested in studying complex trauma. My program has been pretty supportive and I haven't heard arguments against the existence of complex trauma, so I found this comment surprising. Is the argument against the existence of complex PTSD that it can be explained as comorbid PTSD and BPD? I also want to make it clear that EMDR or psychoanalysis would never be my treatment of choice. Just genuinely curious about the arguement against it since the research on the topic is pretty scarce in comparison to PTSD.

 

[smalltownpsych]

4. this can be used to restrict practice to APA-endorsed treatments via insurance company endorsement/control

This is my biggest concern about these types of “guidelines” because eventually they create barriers to effective treatment. I have already seen that occur. I have been mired in the medical model for the last four years and seen the fallacies inherent in that. I am hopeful that I can soon get back to the private pay world where the wealthy and educated pay significant amounts of money for more than just the RCT tested therapies, including medications, for their kids and themselves. I completely support continued research and utilize evidence based research and many of my patients do just fine with that and fit neatly into the category, but most do not. I work with a lot of people with early maternal abandonment or attachment issues, there isn’t even a diagnosis for them that really applies and there sure as heck isn’t a treatment guideline, but the powers that be use the stuff that we put out to tell me what I am supposed to do and how to do it anyway.

 

[DSMX]

This is my biggest concern about these types of “guidelines” because eventually they create barriers to effective treatment. I have already seen that occur. I have been mired in the medical model for the last four years and seen the fallacies inherent in that. I am hopeful that I can soon get back to the private pay world where the wealthy and educated pay significant amounts of money for more than just the RCT tested therapies, including medications, for their kids and themselves. I completely support continued research and utilize evidence based research and many of my patients do just fine with that and fit neatly into the category, but most do not. I work with a lot of people with early maternal abandonment or attachment issues, there isn’t even a diagnosis for them that really applies and there sure as heck isn’t a treatment guideline, but the powers that be use the stuff that we put out to tell me what I am supposed to do and how to do it anyway.

"Eventually they create barriers to effective treatment"?? These RCTs have consistently shown that these treatments are effective in treating PTSD. Have you tried any of them? And what is the "effective treatment" you are referring to that you think these RCTs serve as barriers to? Please name the treatment(s).

"Early abandonment" and "attachment issues" do not equate to what this thread is about: PTSD, and PTSD treatments.

"many of my patients do just fine with that and fit neatly into the category, but most do not" ... Have you been trained in one of these treatments, and gone through consultation for any of them? If so, which?

 

[Justanothergrad]

No problem. That's what threads like this are for -- so that we can inform each other. I'm pretty sure that document answers all of your questions. Some may still have disagreements about those answers though.

It looks pretty solid on the methodological front. I'm still not in agreement in how they define what a successful treatment is [mostly its Tx versus Waitlist control with an insufficient number of studies in the other cases]. If they are going to recommend specific therapies, they should substantially out perform other therapies not "no therapy". We know therapy is better than no therapy, and there isn't a lot of support suggesting that one therapy outperforms another with any sort of substantial effect.

"many of my patients do just fine with that and fit neatly into the category, but most do not" ... Have you been trained in one of these treatments, and gone through consultation for any of them? If so, which?

I can't speak for smalltown, but I've been trained extensively in CPT and PE treatments for in outpatient and inpatient VA settings. What I've found is the same as what he has been saying, and it is the same as I have heard in talking with many other PTSD researchers/providers (e.g., PCT team leaders, and those who have been trained)- these aren't always the treatments for everyone (I don't personally think it should surprise us that people vary). This general consensus also includes some (almost all that I've talked to, but I haven't really kept a tally) national trainers- most recently had a lengthy conversation with a trainer in TFCBT (I know its slightly different, but its an EST for PTSD so it exemplifies my point). This is part of the reason the screening process for the inpatient PTSD units is so strict. It is also why so deviations occur in manualized outpatient treatments (e.g., CPT; Galovski et al., 2012) . In my opinion, this is part of the reason why so many drop out (Najavitis, 2015) or attend a number of sessions not equal to a full dosage for either treatment. For instance, in a sample of around 800 CPT/PE cases from around the country, 52% of veterans don't complete the entire protocol for either CPT or PE and a substantial portion of those who initiate treatment drop within the first few sessions when the risk for increased symptom severity is highest (Rutt et al, 2017). Likewise, in a sample of 2,000 vets across the northeast region who initiated EBP treatment, there was a mean of 5 sessions varying by site from 2-9 sessions (Watt et al., 2014). My belief that individual differences in retention and utilization is also supported empirically (e.g., Doran et al., 2017). Taken together, these factors may be part of why efforts of the VA to promote use of EBP is only modestly effective, even when major implementation roll-outs are conducted (Watts et al., 2014). This doesn't mean I don't like CPT/PE. I do. I like it a lot and so do the folks I talk to who use it. That doesnt make it perfect for everyone.

This all hints at the conceptual question I always get stuck on with EBP. After so many deviations and alterations (both major and minor), at what point is the therapy no longer the manualized treatment it is intended to be, and should we care? If some form of deviation is the rule rather than the exception (which is what appears to be true- with the type of deviation varying by person, context, and need), why are we pretending it isn't? Part of my frustration with the EBP movement is that it takes the encyclopedia and jams it down into a readers digest entry of 'what to do to feel better'.

 

[Fan_of_Meehl]

This is my biggest concern about these types of “guidelines” because eventually they create barriers to effective treatment. I have already seen that occur. I have been mired in the medical model for the last four years and seen the fallacies inherent in that. I am hopeful that I can soon get back to the private pay world where the wealthy and educated pay significant amounts of money for more than just the RCT tested therapies, including medications, for their kids and themselves. I completely support continued research and utilize evidence based research and many of my patients do just fine with that and fit neatly into the category, but most do not. I work with a lot of people with early maternal abandonment or attachment issues, there isn’t even a diagnosis for them that really applies and there sure as heck isn’t a treatment guideline, but the powers that be use the stuff that we put out to tell me what I am supposed to do and how to do it anyway.

I think some of the leading folks--even in CBT--such as Beck, Barlow, Hayes et al. agree that the manualized-protocol-treatment for specific diagnosis/syndrome model is sub-optimal to utilize (exclusively) in routine outpatient practice and they seem to be moving to a more flexible and responsive model involving rigorous training in ensuring therapists have competency to deliver transdiagnostically effective (and empirically-supported) principles of behavior change such as arousal reduction strategies, psychoeducation, exposure, cognitive-restructuring, problem-solving, assertiveness, etc. Check out their new book, Process Based CBT just published in 2018. I think they're onto something.

Process-Based CBT

It's a great resource and, according to the 'big dogs' in the field, represents a crucial turning point in how we conceptualize 'science-based' practice of clinical psychology--both at the graduate training level (how programs are constituted) as well as how professional psychotherapy is practiced. I'm as 'pro-structure,' 'pro-agenda,' and 'pro EBT' as anyone you'd ever meet. I also have the experience of attempting to get my veteran clients (in a post-deployment clinic) to accept/tolerate the highest level of therapeutic structure (agendas, worksheets, between-session assignments, time limited and goal-focused therapy) that they would tolerate and I found something interesting (over the past three years): there's something different going on in this population. I don't know exactly what it is (I have some hypotheses) but if you go into practicing with this population with the expectation that they will either accept an EBT protocol (PE/CPT) for a time-limited course of psychotherapy or they won't be 'appropriate' for your clinic, then you're going to have about 1 to 3 clients in your caseload. I don't care if you try to implement motivational interviewing before or during your attempts at CBT...same resistances. It's just a reality. Also, I don't think the developers of many of the protocols ever intended to transform the field into a full-on 'let's fully embrace the medical model at all costs' and let's take a purely plug-and-play approach to case formulation and treatment planning. There are also a couple of 'elephants' in the room that no one ever discusses that complicate the: my client 'has PTSD' so let's plug him/her into a protocol model of case formulation and treatment planning, namely: (1) at least in the VA system, when I get a client someone has diagnosed with PTSD, it's a literal coin-flip whether they *actually* have PTSD according to DSM-5 criteria and careful assessment--differential diagnosis in the VA system is, generally, piss-poor (though I'm sure it's much better at, say, the Boston VA); (2) for better or worse, with the service-connection (monthly payments for disability due to PTSD) reality, the assumption that veteran self-report on checklists of their symptoms is some sort of pure measure of their level of psychopathology/disability is dubious, at best. Finally, to my knowledge, there has *never* been a study that has examined the rates of uptake (i.e., veterans who agree to a trial of an EBT protocol in-the-first-place) as a factor in the effective use of EBT protocols. What I mean is that the current research database (even with consideration of drop-outs) makes the assumption that every veteran is going to be willing/able to begin participation in an EBT protocol (whether they drop out or not). This has not been my experience on the 'front-lines' of service delivery in the veteran population. There are numerous 'client-side' barriers to EBT uptake and these--in my experience--are the 'rate limiting' variables in EBT uptake (at least they have been in my clinic).

 

[WisNeuro]

I'm in grad school and have become increasing interested in studying complex trauma. My program has been pretty supportive and I haven't heard arguments against the existence of complex trauma, so I found this comment surprising. Is the argument against the existence of complex PTSD that it can be explained as comorbid PTSD and BPD? I also want to make it clear that EMDR or psychoanalysis would never be my treatment of choice. Just genuinely curious about the arguement against it since the research on the topic is pretty scarce in comparison to PTSD.

Been a while since I looked into it, I don't publish in the PTSD realm any more. At the time I last delved into it, the symptom overlap was pretty telling. I have not yet seen anything that would compellingly show that the symptoms of what people term "complex trauma" are distinct in any way. Additionally, the way that it was treated was just utilizing PE/CPT and DBT approaches. Exactly what you'd do for someone with Borderline PD with symptoms of PTSD. I'm willing to be convinced, but at that point in time, it just seemed like a way for the dynamic people to insert themselves into the treatment framework.

 

[DailyJoy]

Been a while since I looked into it, I don't publish in the PTSD realm any more. At the time I last delved into it, the symptom overlap was pretty telling. I have not yet seen anything that would compellingly show that the symptoms of what people term "complex trauma" are distinct in any way. Additionally, the way that it was treated was just utilizing PE/CPT and DBT approaches. Exactly what you'd do for someone with Borderline PD with symptoms of PTSD. I'm willing to be convinced, but at that point in time, it just seemed like a way for the dynamic people to insert themselves into the treatment framework.

Thanks WisNeuro. I really appreciate the response.

 

[DSMX]

I can't speak for smalltown, but I've been trained extensively in CPT and PE treatments for in outpatient and inpatient VA settings. What I've found is the same as what he has been saying, and it is the same as I have heard in talking with many other PTSD researchers/providers (e.g., PCT team leaders, and those who have been trained)- these aren't always the treatments for everyone (I don't personally think it should surprise us that people vary). This general consensus also includes some (almost all that I've talked to, but I haven't really kept a tally) national trainers- most recently had a lengthy conversation with a trainer in TFCBT (I know its slightly different, but its an EST for PTSD so it exemplifies my point). This is part of the reason the screening process for the inpatient PTSD units is so strict. It is also why so deviations occur in manualized outpatient treatments (e.g., CPT; Galovski et al., 2012) . In my opinion, this is part of the reason why so many drop out (Najavitis, 2015) or attend a number of sessions not equal to a full dosage for either treatment. For instance, in a sample of around 800 CPT/PE cases from around the country, 52% of veterans don't complete the entire protocol for either CPT or PE and a substantial portion of those who initiate treatment drop within the first few sessions when the risk for increased symptom severity is highest (Rutt et al, 2017). Likewise, in a sample of 2,000 vets across the northeast region who initiated EBP treatment, there was a mean of 5 sessions varying by site from 2-9 sessions (Watt et al., 2014). My belief that individual differences in retention and utilization is also supported empirically (e.g., Doran et al., 2017). Taken together, these factors may be part of why efforts of the VA to promote use of EBP is only modestly effective, even when major implementation roll-outs are conducted (Watts et al., 2014). This doesn't mean I don't like CPT/PE. I do. I like it a lot and so do the folks I talk to who use it. That doesnt make it perfect for everyone.

This all hints at the conceptual question I always get stuck on with EBP. After so many deviations and alterations (both major and minor), at what point is the therapy no longer the manualized treatment it is intended to be, and should we care? If some form of deviation is the rule rather than the exception (which is what appears to be true- with the type of deviation varying by person, context, and need), why are we pretending it isn't? Part of my frustration with the EBP movement is that it takes the encyclopedia and jams it down into a readers digest entry of 'what to do to feel better'.

Thank you for the very well-thought out response. There are many factors which can contribute to the dropout you cited in this post. I think when we hear dropout, we automatically assume that the treatment wasn't appropriate for the client. Furthermore, some then attribute that to its manualized nature. We could also point out how many people improved in the studies you cited. Additionally, we could cite the many studies which are informing these guidelines, which do show patient improvement.

There are so many other potential factors which need to be examined when it comes to dropout, including: therapist knowledge of the protocol, therapist comfort, therapist confidence, time allotted for the manualized treatments (e.g., ideally 60 mins for CPT and 90 mins for PE), therapist avoidance, client avoidance (e.g., maybe willing to talk about one trauma, but not what would be the "true" index trauma) -- but this could even be attributable to a therapist who hasn't been trained to help the client identify the index trauma.

It could also be said that if a therapist hasn't been properly trained, and then the hesitancy is somehow communicated to the patient, that doesn't instill much confidence in the patient about the therapy.

Even before all of this, these are PTSD treatments. One is already starting behind if they begin a PTSD treatment with a client who doesn't actually have PTSD -- which necessitates proper diagnostic procedures (not just a high PCL score).

 

[DSMX]

then you're going to have about 1 to 3 clients in your caseload. I don't care if you try to implement motivational interviewing before or during your attempts at CBT...same resistances. It's just a reality.

I know of several VA PTSD clinics across VA systems nationwide whose therapists have caseloads almost completely devoted to EBPs for PTSD. So, this "1 to 3" you're suggesting is not at all typical.

(1) at least in the VA system, when I get a client someone has diagnosed with PTSD, it's a literal coin-flip whether they *actually* have PTSD according to DSM-5 criteria and careful assessment--differential diagnosis in the VA system is, generally, piss-poor (though I'm sure it's much better at, say, the Boston VA); (2) for better or worse, with the service-connection (monthly payments for disability due to PTSD) reality, the assumption that veteran self-report on checklists of their symptoms is some sort of pure measure of their level of psychopathology/disability is dubious, at best.

I do agree with these points. Service-connection should never inform clinical care. Which is why when one gets a referral to potentially deliver an EBP for PTSD, they should do a proper diagnostic interview themselves. We are very aware that providers in other disciplines might hear "nightmare" and automatically refer that patient for PTSD treatment, for example. So the onus to properly determine if the client has PTSD should be on the one who is going to deliver the EBP. Fortunately this does occur at many specialized PTSD clinics in the VA system, however not all (not to mention CBOS which might have a resource strain to begin with).

 

[Fan_of_Meehl]

I know of several VA PTSD clinics across VA systems nationwide whose therapists have caseloads almost completely devoted to EBPs for PTSD. So, this "1 to 3" you're suggesting is not at all typical.

Are these 'specialty' clinics? Yeah, we have those, too. How about open-entry clinics like post-deployment clinics or general mental health clinic populations? Clinics that have no 'lower level' of care to refer out to should the client not wish to engage in a specific protocol.


I do agree with these points. Service-connection should never inform clinical care. Which is why when one gets a referral to potentially deliver an EBP for PTSD, they should do a proper diagnostic interview themselves. We are very aware that providers in other disciplines might hear "nightmare" and automatically refer that patient for PTSD treatment, for example. So the onus to properly determine if the client has PTSD should be on the one who is going to deliver the EBP. Fortunately this does occur at many specialized PTSD clinics in the VA system, however not all (not to mention CBOS which might have a resource strain to begin with).

I know of several VA PTSD clinics across VA systems nationwide whose therapists have caseloads almost completely devoted to EBPs for PTSD. So, this "1 to 3" you're suggesting is not at all typical.



I do agree with these points. Service-connection should never inform clinical care. Which is why when one gets a referral to potentially deliver an EBP for PTSD, they should do a proper diagnostic interview themselves. We are very aware that providers in other disciplines might hear "nightmare" and automatically refer that patient for PTSD treatment, for example. So the onus to properly determine if the client has PTSD should be on the one who is going to deliver the EBP. Fortunately this does occur at many specialized PTSD clinics in the VA system, however not all (not to mention CBOS which might have a resource strain to begin with).

Our local 'specialty PTSD' clinic is one of the biggest offenders in terms of churning out PTSD diagnoses based merely on something like the PCL-5 (self-report checklist) and/or failing to do any serious interviewing regarding whether or not the veteran actually experienced a Criterion A stressor and/or whether or not other comorbid issues (substance abuse, personality disorder, other anxiety disorders) have been examined or ruled in/out for their contribution to current symptom presentation. Our 'specialty clinic' also has the luxury of only accepting the cases they wish to accept according to their inclusion criteria (you know, just like the empirical investigations that examine EBP protocol efficacy). And, when a veteran enters into a 'protocol treatment' (such as PE) in the 'specialty clinic' with a PCL-5 score of 76 (out of 80), lol, and then, 12 weeks later, finishes up with a PCL-5 score of 78 (out of 80)--without a single line in the progress notes regarding the veteran's complete lack of progress and without a shred of apparent thought relating to whether or not the techniques were being appropriately applied or whether within- or between-session habituation had been occurring, or new learning had been taking place, or whether the treatment had been applied with fidelity--the mechanisms of change espoused by the theoretical model). This sort of case has been described by them as 'achieving optimal benefit from therapy' (I kid you not) and is then 'discharged.' These sorts of veterans then end up in general admission clinics (such as post-deployment). The veterans who present to these clinics for care are not the same population that make it through all of the exclusion criteria for inclusion in the efficacy studies.

 

[cara susanna]

I was in a specialty PTSD clinic in my last job and we gave the CAPS to everyone. But, yeah, our caseload was primarily CPT and PE, with groups that were meant to get people ready for eventual trauma-focused work. Now I'm in a general MH clinic where we don't have any specialty teams, so I have a lot of PTSD cases but I'm only doing EBPs with a few people because we're only allowed to have so many dedicated EBP slots. I'm trying to strike a balance between delivering treatments that work while also meeting the patient where they're at. I had to learn that in my last job because I couldn't just stop seeing patients out if they weren't ready for a trauma EBP.

As for complex PTSD, there's mixed research. Most research suggests that it's not conceptually distinct from BPD, but Marylene Cloitre has some research suggesting otherwise. There actually isn't a lot of research suggesting that complex trauma histories or interpersonal trauma histories do any worse in PE or CPT or need skills building prior to trauma-focused work, but clinically I've definitely seen it (ancedotally, of course). Generally, most of the research on PE and CPT dropout indicates that it's for other reasons, like scheduling problems.

 

[DynamicDidactic]

For those that are in support but haven't signed the petition
Sign Petition: Support the APA PTSD Treatment Guidelines

 

[DynamicDidactic]

Process-Based CBT

Good looking book. It surprisingly difficult to find an updated and encompassing CBT training book. I'll have to give this one a whirl.

 

[Pragma]

I find the opposition to the guidelines to be a bit concerning. I'm very careful about who I refer people to for therapy, because from what I have seen, there are a lot of practitioners out there that don't even consider or stay informed about evidence-based treatment, let alone make an effort to learn and implement them.

 

[smalltownpsych]

"Eventually they create barriers to effective treatment"?? These RCTs have consistently shown that these treatments are effective in treating PTSD. Have you tried any of them? And what is the "effective treatment" you are referring to that you think these RCTs serve as barriers to? Please name the treatment(s).

"Early abandonment" and "attachment issues" do not equate to what this thread is about: PTSD, and PTSD treatments.

"many of my patients do just fine with that and fit neatly into the category, but most do not" ... Have you been trained in one of these treatments, and gone through consultation for any of them? If so, which?

I have been trained in CR for trauma and it has a strong evidence base, I just can't seem to get very many patients to do it for a wide variety of reasons. What I was getting to with those other problems is that those patients don't have a diagnosis that fits neatly into DSM categories, but many, if not most of those patients have experienced significant trauma. Abandoned by mom in infancy is a pretty big trauma, but I can't seem to find any evidence-based treatments for that. What about molested from age 5 on? Typically these patients get PTSD and MDD diagnosis and potentially Borderline (they have often been dx'ed with ADHD a few times too), but when I am six months into treatment and someone say they should have been treated by now - that is when I get frustrated.

 

[Fan_of_Meehl]

Good looking book. It surprisingly difficult to find an updated and encompassing CBT training book. I'll have to give this one a whirl.

I'd also enthusiastically recommend David Tolin's new book on 'Doing CBT'
Doing CBT: A Comprehensive Guide to Working with Behaviors, Thoughts, and Emotions

Dr. Tolin does a fantastic job teaching the foundational philosophy of science precepts underlying a science-based approach to clinical assessment, case formulation, and intervention. He understands that science is not a compendium of 'answers' (especially in our field), but rather a particular approach to utilizing hypothesis formation, testing, and revision processes to continually revise our models of the world (in this case, particular clients and the troubles they face in living). Fallibility, doubt, and skepticism (especially toward one's own particular model of the world or how things are supposed to work) are the hallmarks of science.

 

[cara susanna]

Wanted to add to my comment about complex PTSD because I just reviewed the more recent literature on it. Basically, it also may not be diagnostically distinct from "traditional" PTSD, especially given the updated DSM-5 criteria. So, there are questions about diagnostic overlap with BPD and PTSD as well.

 

[WisNeuro]

Wanted to add to my comment about complex PTSD because I just reviewed the more recent literature on it. Basically, it also may not be diagnostically distinct from "traditional" PTSD, especially given the updated DSM-5 criteria. So, there are questions about diagnostic overlap with BPD and PTSD as well.

So, what is the argued for clinical utility of such a diagnosis if it is neither distinct from a diagnostic setting, nor is it distinct from a treatment recommendation point?

 

[cara susanna]

So, what is the argued for clinical utility of such a diagnosis if it is neither distinct from a diagnostic setting, nor is it distinct from a treatment recommendation point?

Well, the people who argue for its inclusion do think that it's diagnostically distinct. There is some research they've conducted that they argue shows that it is.

 

[WisNeuro]

Well, the people who argue for its inclusion do think that it's diagnostically distinct. There is some research they've conducted that they argue shows that it is.

Is there any independent clinical data that supports the notion, or is it still coming out of two camps?

 

[cara susanna]

It mostly seems to be from the two camps that I associate with promotion of complex PTSD. That being said, I haven't looked at everything that's out there.

 

[Harry3990]

It mostly seems to be from the two camps that I associate with promotion of complex PTSD. That being said, I haven't looked at everything that's out there.

One way I have come to appreciate the distinction of Complex PTSD is as an added qualifier or "severe" marker in terms of the duration and intensity of the trauma. Sure, it might look very similar to BPD with PTSD, but why not have something diagnostic that is emphasizing the "complex" nature of the ongoing trauma rather that needs to be considered when selecting treatments and trying to help make sure that they aren't constantly dissociating or psychotic (MDD with psychotic features has a high comorbidity with C-PTSD according to some of these studies).

Admittedly, in my experience the C-PTSD distinction is not something I'm ever really documenting but rather using as a way conceptualizing for myself and guiding treatment. However, if it was in the DSM, I'd probably use it as a way indicating increased severity of PTSD in the same way the DSM5 encourages the use of spectrum consideration with other diagnoses.

Typically these patients get PTSD and MDD diagnosis and potentially Borderline (they have often been dx'ed with ADHD a few times too), but when I am six months into treatment and someone say they should have been treated by now - that is when I get frustrated.

I very much agree with this sentiment and empathize with your frustration. Short-term therapy is not going to be effective for everyone. IMO this is more of a misconstruing of the literature's support for short-term EBP's as justifying for administrators that every mental health disorder under the sun should be able to be treated and in remission with such constraints.

 

[WisNeuro]

Admittedly, in my experience the C-PTSD distinction is not something I'm ever really documenting but rather using as a way conceptualizing for myself and guiding treatment. However, if it was in the DSM, I'd probably use it as a way indicating increased severity of PTSD in the same way the DSM5 encourages the use of spectrum consideration with other diagnoses.

Why not just say Severe PTSD and describe some of the predominant features that the person has? I still fail to see how this changes the workup and treatment rec formulation one would take with any patient presenting with PTSD.

 

[Justanothergrad]

That's always confused me as well since PTSD is probably better thought of as a spectrum anyway rather than a bunch of distinct clusters.

 

[Therapist4Chnge]

I wonder if psych testing can differentiate between PTSD and “complex PTSD”? The few cases i’ve seen all have had funky 2RFs....and not surprisingly messy psych histories. I don’t typically see a lot of severe pathology (typical base rates), so i’d be curious to hear from ppl who regularly see PTSD cases.

 

[WisNeuro]

I wonder if psych testing can differentiate between PTSD and “complex PTSD”? The few cases i’ve seen all have had funky 2RFs....and not surprisingly messy psych histories. I don’t typically see a lot of severe pathology (typical base rates), so i’d be curious to hear from ppl who regularly see PTSD cases.

At least in the VA, whenever I saw "Complex PTSD" attached to someone I evaluated, the PVT/SVT failure rates shot up considerably. I pretty much lumped that one into the fibro, lyme, multiple chemical sensitivity in it's use in predicting validity failure.

 

[Fan_of_Meehl]

That's always confused me as well since PTSD is probably better thought of as a spectrum anyway rather than a bunch of distinct clusters.

Exactly. An there is an oft-underappreciated heterogeneity among all cases which may come with a diagnostic label of PTSD. Consider simply the combinatorial possibilities of a polythetic disorder with 20 possible symptoms, at least 1 from Cluster B, 1 from Cluster C, 2 from Cluster D, and 2 from Cluster E (minimum). Someone published an article where they did the combinatory calculations and determined that there are something like 14,000+ different combinations of symptoms that could present as PTSD. And that's just symptom presentation of the PTSD. What about co-morbidity? What about primarily internalizing vs. externalizing psychopathology? What about the nature of and total number of index traumas (think single automobile crash vs. years of rape and physical abuse and torture). What about presence of suicidality/ self-harm behavior as a prioritized clinical target? Each case is the same in ways, yet different in others. Some of these distictly relevant clinical features (severe suicidality, substance abuse, personality pathology, lack of treatment engagement) get screened out in RCT's before patients even make it into the study, some don't). PTSD (even if accurately diagnosed, which, often it isn') is quite a heterogenous category. Of course, it doesn't mean that we can't come up with general rules for therapy (e.g., avoidance is bad, exposure generally works if applied with technical competence and safety behavior is dismantled and habituation occurs)--but this doesn't necessarily mean that we have it all figured out at the level of, 'presence of disorder X = need to plug patient into scripted (session-by-session) protocol Y to treat to remission in Z weeks [end of line].' Let me hasten to add that my goal with all PTSD pts is to get them into a protocol (if possible) but for those who can't or won't, good science-based psychotherapy practice is both desirable and possible.

 

[Therapist4Chnge]

At least in the VA, whenever I saw "Complex PTSD" attached to someone I evaluated, the PVT/SVT failure rates shot up considerably. I pretty much lumped that one into the fibro, lyme, multiple chemical sensitivity in it's use in predicting validity failure.

Same.

I have a “complex PTSD” + mTBI case coming up for assessment, so it’ll be interesting to see how they do. I also have a moderate TBI + (suspected) PTSD case coming up. I have a guess at what their cog and psych profiles will be...but i’ll let it play out and see what the data say.