By: Christine A. Courtois, PhD, ABPP
I write this blog response as a clinician with over 40 years of experience (just retired from practice) and an author/trainer who has devoted my career to the development of treatment approaches for different types of interpersonal trauma. I have recently served as Chair of the American Psychological Association Clinical Practice Guidelines for the Treatment of PTSD in Adults (2017) (the subject of Dr. Shedler’s critique) and over the years have helped develop other professional practice and clinical practice guidelines. I have also long called for the inclusion of the topic of trauma and trauma practice into professional curricula across all professions (Courtois & Gold, 2006) and helped to organize an APA Division 56 (Trauma Psychology) project on competencies in trauma treatment that has resulted in a set of training guidelines (Cook et al., 2014). My interests have very much been focused on not further burdening or harming clients suffering from the effects of trauma.
From my perspective, Dr. Shedler took a very extreme position in response to the APA Clinical Practice Guidelines process and recommendations and was irresponsible in telling therapists to totally ignore this (and by association, other clinical practice guidelines). Moreover, as noted by other responders, he offered a number of ill-chosen analogies to make his points. That said, as someone who is primarily a clinician and a member of the Guideline Development Panel, I well understand the struggles of both clinicians and patients to reconcile guideline treatment recommendations while not losing clinician wisdom, judgement, and patient preference, values, and contextual issues in the process. The recommended treatments have always seemed too narrow in scope to me but they are but one important determination in what should be broad-based treatment. I too have worried that third parties, especially insurance companies, will over-rely on guideline recommended treatments as applicable to all trauma clients at whatever point they are in the treatment process and that my clinical recommendations will be ignored and dismissed. It is my belief that all of the clinicians who served on the panel struggled with these issues in one way or another. And all were concerned about what works and doesn’t in treating trauma and its aftermath (as Dr. Shedler is as well). As discussed below, issues such as these are discussed in the APA guideline document and why a Professional Practice Guideline is being prepared to accompany clinical practice guidelines.
Rather than ignore and trash the entire guideline effort as Dr. Shedler suggests, therapists should be encouraged to view Clinical Practice Guidelines as sources of information regarding the efficacy of various treatments. There are now a number of such guidelines that have been produced by professional organizations and groups (nationally and internationally (see listing in Appendix A)) and these can be cross-referenced by the interested clinician. They can also be supplemented by other authoritative and peer-referenced writings and by Professional Practice Guidelines that outline the needs of a special population or issue that range well beyond efficacy studies only. These are written specifically to assist the practicing clinician to anticipate and manage more process-related interpersonal (transference, countertransference, vicarious trauma and vicarious resilience issues among them), contextual (diversity and generalizability) and content issues. APA (2016) has specified the differences in the two types of guidelines.
Controversies about evidence-based practice in psychology have been ongoing and are likely to continue. In response to the polarization of viewpoints, APA has identified three “legs of the stool” for evidence-based practice, in the process distinguishing itself from other behavioral health professions: 1) empirical evidence derived from research findings (Randomized Clinical Trials best for determining efficacy yet other methods relevant for important questions); 2) clinical judgment (including knowledge of the client’s condition and needs); 3) client preference, values, and context (American Psychological Association, 2006). As Dr. Shedler (and many other writers) correctly note, RCT’s are not perfect nor are they without weaknesses and the body of high quality RCT’s for the treatment of trauma symptoms is limited at this point (as was pointed out in the guideline document). Moreover, it is recognized that political and social issues and past research findings in support of a particular treatment may make research funding for the newer methodologies hard to come by, leading to possible bias and to asymmetry in the approaches that are funded for research. And, no doubt, shorter-term treatments lend themselves to being easier to research. Panel members made many recommendations for filling in research gaps in future efforts and it should be noted that research studies are becoming more sophisticated over time.
A presentation at the recent annual conference of the International Society for Traumatic Stress Studies (ISTSS) entitled “Clinical Practice Guidelines: Are They Still Clinical?” (Kudler et al., 2017) stressed the need for balance among sources of information and cited the importance of various knowledge sources and types of research and ongoing innovation. Various organizations including Division 12 of APA and the National Register of Evidence-Based Practices and Procedures (NREPP, SAMSHA) have produced listings of evidence-suggested and evidence-based practices that are not always based on RCT’s and thus are not as rigorously evaluated as in a systematic review but are valuable nonetheless in providing clinicians with information about treatments that are emerging and have some research evidence to support them. At the present time, there are also efforts underway to otherwise discern the efficacy of emerging treatments (See Metcalf et al., 2016 review of RCT’s for emerging therapies). Notably, several of these are physiologically-based treatments and offer preliminary evidence in support of the current emphasis on mind-body treatment of trauma.
The Institute of Medicine standards for developing Clinical Practice Guidelines guided development of the APA Clinical Practice Guidelines for the Treatment of PTSD in Adults
Below is a brief outline of the process that was followed by the APA Guideline Development Panel so that readers know it was not a “fly-by-night” effort and that it involved extensive evaluation and consideration. A more detailed description can be found in the document itself and in the article by Hollon et al. (2014).
Over the past decade, the leadership of APA determined a need for the development of high-quality clinical practice guidelines in keeping with those produced by other national and international health professions. A decision was made to rely on the process developed by the Institute of Medicine (2011a & b), the current “gold standard” by which clinical practice guidelines are developed, obviously quite a change and a challenge for APA. The treatment of PTSD was among the original three topics to be proposed and approved for clinical practice guideline development. An eleven member multidisciplinary group of experts in various aspects of PTSD treatment and research methodology and two consumer members was convened in 2012. As part of the transparency process, nominees completed extensive conflict of interest disclosures (financial as well as theoretical/intellectual). No developers of treatments were members of the panel, although it was acknowledged and encouraged that members would have differences in theoretical orientation and perspectives to bring to the discussions. The PTSD panel was the first to complete a process that lasted more than 4 years due to the learning curve regarding the methodology (for both supporting staff and members of the panel) and to have its guideline accepted by the APA Council of Representatives (February 2017).
The primary evidence base for the guideline was the systematic review of the treatment literature, Psychological and Pharmacological Treatments for Adults with Posttraumatic Stress Disorder (PTSD) (Jonas et al., 2013) produced for the Agency for Healthcare Research and Quality (AHRQ) by the Research Triangle International- University of North Carolina Evidence-Based Practice Center (RTI-UNC EPC). The comprehensive and transparent systematic review of available RCT’s addressed psychological and pharmacological treatments for PTSD. It addressed the following Key Questions: 1) What is the efficacy of psychological and medication treatments for adults with PTSD, compared to no treatment or to inactive controls? 2) What is their comparative effectiveness (i.e., psychological treatments compared to other psychological treatments, medication treatments compared to other medication treatments, and psychological treatments compared to medication treatments)? 3) Which treatments work best for which patients? In other words, do patient characteristics or type of trauma modify treatment effects?
4) Do serious harms of treatments or patient preferences influence treatment recommendations?
The review followed the protocol set forth by the Institute of Medicine (2011b) of first identifying hundreds of studies and determining whether studies met the inclusion/ exclusion criteria then a detailed evaluation of the quality of the studies in terms of risk of bias, precision, consistency, and directness. The stringency of the evaluative process resulted in a high exclusion rate, a limited number of studies on which to base recommendations, and thus to more restricted findings. Once the studies were compiled and analyzed, panel members conducted a detailed review and independent analysis of the findings. They considered four factors as they drafted recommendations: 1) overall strength of the evidence; 2) the balance of benefits vs. harms/burdens; 3) patient values and preferences; and 4) applicability. Based on the combination of these factors, the panel made a strong or conditional recommendation for or against each particular treatment or made a statement that there was insufficient evidence to be able to make a recommendation for or against.
The following recommendations were made for treatment interventions for adult patients with PTSD (listed in alphabetical order): cognitive behavioral therapy (CBT), cognitive processing therapy (CPT), cognitive therapy (CT), and prolonged exposure therapy (PE). The panel suggested brief eclectic psychotherapy (BEP), eye movement desensitization and reprocessing (EMDR), and narrative exposure therapy (NET). For medications, the panel suggested offering the following (in alphabetical order): fluoxetine, paroxetine, sertraline, and venlafaxine. With some exceptions, the APA PTSD treatment guideline recommendations and suggestions are consistent with guideline recommendations previously published by other professional associations and organizations. Therefore, at the present time, research support is most available for CBT-based techniques; however, techniques such as EMDR–based on additional type of processing beyond the fear and cognitive processing of CBT–and Brief Eclectic Psychotherapy that works largely from a psychoanalytic and psychodynamic base received conditional recommendation.
In the section on research gaps and in the guideline summary, the panel noted that the available PTSD treatment research is substantial but requires increased sophistication in design and methodology to study the expanded range of treatments that are now available. Panel members support the ongoing research pertaining to treatment process, outcome, and relational dimensions, in general and as it applies more specifically to work with traumatized individuals, and hope to have it incorporated in future guidelines. These guidelines will be reviewed in five years following adoption as policy with a decision to update, revise, or sunset the document made at that time. It is of note that the Agency for Healthcare Research and Quality has commissioned additional systematic reviews on psychosocial treatments and psychopharmacology for PTSD that may provide the data for revision to the guidelines[1].
The draft of the guideline document was posted for a two months’ public comment period that resulted in more than 800 responses, many of them from clinicians whose concerns were similar to those expressed by Dr. Shedler. These were reviewed and responded to individually or in aggregate by the panel. Parts of the guideline were modified in response to the comments and the final document was presented to the APA Council of Representatives at its February 2017 meeting. In accepting the guideline, Council members suggested a “preamble” be written highlighting certain key issues and this document was written and posted with the guideline (see Placing Clinical Practice Guidelines in Context.) Throughout the guideline and this context document, it is noted that guidelines are not standards nor mandatory and that they are aspirational. Clinicians are advised to be familiar with guidelines and to incorporate them into their treatment plans as they determine their recommendations’ applicability to a particular client and clinical situation. In addition, and in response to clinician concerns and also to the fact that these guidelines are narrowly directed to the reduction of symptoms of PTSD on the basis of a highly-vetted set of RCT’s, the Council directed a companion Professional Practice Guideline (PPG) to address many of the issues and concerns related to good clinical care of trauma survivors not addressed by the CPG
I hope this brief overview provides rationale for the process and the findings. Rather than ignore them or to treat them as “bad therapy”, I encourage clinicians to use them in informing their traumatized clients about what treatments have been found to work so far in reducing symptoms of PTSD and in helping them evaluate and select interventions. They can also discuss other more process-oriented, psychodynamic, and relationally-based techniques that are routinely used for the other clinical concerns found in many of these clients who have comorbid diagnoses and issues related to their identity and self-worth, including shame, guilt, responsibility, morality, and spirituality and some are highly dissociative. Clinicians have been highly creative in developing innovative techniques to treat the range of posttraumatic stress disorders. Now research needs to catch up–clinical researchers need to continue the development of innovative and rigorous methodologies to study these emerging treatments as to their efficacy, effectiveness, and applicability. Trauma survivors deserve nothing less.
References
American Psychological Association Clinical Practice Guidelines for the Treatment of PTSD in Adults
(2017). Washington, DC: Author. http://www.apa.org/about/offices/directorates/guidelines/clinical-practice.aspx
American Psychological Association. (2015). Professional Practice Guidelines: Guidance for developers and users. American Psychologist, 70(9), 823-831, doi: 10.1037/a0039644.
American Psychological Association (2006). Evidence-based practice in psychology. American Psychologist, 61(4), 271-285.
Cloitre, M., Courtois, C.A., Charuvastra, A., Carapezza, R., Stolbach, B.C., et al. (2011). Treatment of complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress, 24(6): 615-627.
Cook, J. M., Newman, E., & the New Haven Trauma Competency Work Group. (2014). A consensus statement on trauma mental health: The New Haven Competency Conference process and major findings. Psychological Trauma: Theory, Research, Practice and Policy, 6, 300-307.
Courtois, C. A., & Gold, S. N. (2009). The need for inclusion of psychological trauma in the professional curriculum: A call to action. Psychological Trauma: Theory, Research, Practice, and Policy, 1(1), 3-23.
Hollon, S. D., Arean, P. A., Craske, M. G., Crawford, K. A., Kivlahan, D. R., Magnavita, J. J. et al. (2014). Development of clinical practice guidelines. Annual Review of Clinical Psychology, 10, 213-241.
Institute of Medicine. (2011a). Clinical practice guidelines we can trust. Washington, DC: The National Academies Press.
Institute of Medicine. (2011b). Finding what works in health care: Standard for systematic reviews. Washington, DC: The National Academies Press.Jonas D. E., Cusack, K., Forneris, C. A., Wilkins, T. M., Sonis, J., Middleton, J. C., Feltner, C., Meredith, D., Cavanaugh, J., Brownley, K. A., Olmsted, K. R., Greenblatt, A., Weil, A., Gaynes, B. N. (2013) Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder (PTSD). Comparative Effectiveness Review No. 92. (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). AHRQ Publication No. 13-EHC011-EF. Rockville, MD: Agency for Healthcare Research and Quality; April 2013. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
Kudler, H. (Chair) (2017). Clinical Practice Guidelines: Are They Still Clinical? Panel presented at the Annual Convention of the International Society for Traumatic Stress Studies, Chicago, IL.
Metcalf, O., Varker, T., Forbes, D., & Phelps, A., et al. (2016). Efficacy of fifteen emerging interventions for the treatment of Posttraumatic Stress Disorder: A systematic review. Journal of Traumatic Stress, 29(1):88-92. doi: 10.1002/jts.22070.Shedler, J. (November 19, 2017). Selling bad therapy to trauma victims. Psychology Today blog.
Appendix A
Clinical Practice and Professional Practice Guidelines for the Treatment of PTSD
American Psychiatric Association (2004). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Washington, DC: Author.
American Psychological Association (2017). Clinical practice guideline for the treatment of PTSD in adults. Author. www.apa.org/ptsd-guideline
Australian Centre for Posttraumatic Mental Health, University of Melbourne (2007, 2013). Available at httt.//www.acpmh.unimelb.edu.au/Resources/video/guidelinesvideo.html.
Clinical Resource Efficiency Support Team (CREST) (2003). The management of Posttraumatic Stress Disorder in Adults. Belfast: Author.
Cloitre, M., Courtois, C. A., Charuvastra, A. Carapezza, R., Stolbach, B. C., & Green, B. L. (2011). Treatment of complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress, 24, 615-627.
Foa, E., Davidson, J. R. T., & Frances, A. (1999). Treatment of Posttraumatic Stress Disorder. The Journal of Clinical Psychiatry, 60, Supplement 16.
Foa, E., Friedman, M., & Keane, T. (2000) Effective treatment for PTSD: Guidelines from the International Society of Traumatic Stress Studies. New York, NY: Guilford Press.
Foa, E., Keane, T., Friedman, M., & Cohen, J. (2009). Effective treatment for PTSD: Guidelines from the International Society of Traumatic Stress Studies. New York, NY: Guilford Press.
Institute of Medicine of the National Academies (2006). Posttraumatic stress disorder: Diagnosis and assessment. Washington, DC: Author.
International Society for the Study of Trauma and Dissociation. (2011). [Chu, J.A., Dell, P.F., Van der Hart, O., Cardeña, E., Barach, P.M., Somer, E., Loewenstein, R.J., Brand, B., Golston, J.C., Courtois, C.A., Bowman, E.S., Classen, C., Dorahy, M., Şar, V., Gelinas, D.J., Fine, C.G., Paulsen, S, Kluft, R.P., Dalenberg, C.J., Jacobson-Levy, M., Nijenhuis, E.R.S., Boon, S., Chefetz, R.A., Middleton, W., Ross, C.A., Howell, E., Goodwin, G., Coons, P.M., Frankel, A. S., Steele, K., Gold, S. N., Gast, U., Young, L.M., & Twombly, J.]. Guidelines for Treating Dissociative Identity Disorder in Adults. McLean, VA: Author.
Kezelman, C. & Stavropoulos, P. (2012). The last frontier: Practice guidelines for treatment of complex trauma and trauma informed care and service delivery. Kirribilli, Australia: Adults Surviving Child Abuse (ASCA). www.asca.org.au
McFetridge, J., Swan, A. H., Heke, S., Karatzias, T., Greenberg, N., Kitchiner, N. et al.. (2017). Guideline for the treatment and planning of services for complex post-traumatic stress disorder in adults. UK Psychological Trauma Society.
National Institute for Clinical Excellence. (2005). Post-traumatic Stress Disorder (PTSD): The management of PTSD in adults and children in primary and secondary care. London: Author.
U.S. Department of Veterans’ Affairs/Department of Defense (2017): http.//www/cqp.med.va.gov/PTSD
[1] This updated review is available for public comment until December 29, 2017 at https://effectivehealthcare.ahrq.gov/node/31598.
