When I run my workshops and webinars on PTSD, I am keen to highlight that the practical techniques and treatment protocols I use and refer to are based on solid evidence as to their effectiveness. But how do we assess the evidence for what is effective in the treatment of PTSD and related areas of the impact of trauma? For me, the key is to look not just at individual evaluation trials but also at the bigger picture of what all these individual studies are telling us when considered together. If we asked a client how they get on with people and they said they got on very well with their next door neighbour we would probably press them on how they got on with wide range of people in different contexts and not just rely on their experience with that one person. The same applies to assessing what works in the area of treating PTSD. We also need to be specific and nuanced. What works best for complex PTSD cases might not work in less complex cases; what works when we are able to intervene early, might not work if the trauma occurred a long time ago.
What works best then to treat Post Traumatic Stress Disorder (PTSD)? Is it Cognitive behavioural therapy (CBT) or the more targeted Trauma Focused CBT (TF-CBT)? What about Exposure Alone treatment or eye movement desensitisation and reprocessing (EMDR)? Do any of them work? And are there specific types of intervention in these approaches which seem to be particularly effective? To answer these questions we cannot rely on the instinct of individual therapists or their overall impressions. One therapist can only treat a limited number of clients over a given period, and their opinion, however well thought through, will inevitably be subjective – and possibly biased.
We need good objective evidence from studies which are able to run a fair test of the effectiveness of a given approach. It’s no good having unfair tests with say a whole set of very experienced therapists treating mild PTSD symptoms being compared with a set of rookie therapists with set of severely traumatised clients. We need studies which – as far as possible – compare the two or more approaches on similar clients with similar therapists under similar conditions.
Let’s take a step back and think about how we might want to look at the evidence from research. When we want to understand whether therapeutic intervention X works better than intervention Y – and whether either of them work at all – we can run a single study and try to maximise the quality (internal validity) of that study. We might do this for example by randomly allocating clients to different treatments to avoid bias and also perhaps have the clients assessed by indepedent assessors not involved in the original treatment (to prevent clinicians ‘marking their own homework’). But as important as it is, one study on its own cannot really tell us too much – there might have been distinctive features of the study which don’t translate well to other settings, contexts or clients.
One way of addressing this issue is to stand back periodically and look at all the well-designed studies in an area and see what the overall pattern is, getting away from the quirks of individual studies. These reviews or meta-analyses as they are sometimes called can take time to do and often require a group of experts to look at all the studies objectively. Technical analyses can help assess specific statistics when we pool the data from several different experiments. However, they are a very powerful way of answering questions as to whether a certain type of therapeutic intervention works or not, and whether it is meaninfully better than some other type of intervention.
In the past 18 months there have a been a few of these meta-analyses in the area of PTSD. Three in particular have important implications for how we view different kinds of therapeutic interventions. The first of these by Karatzias and his team looked at complex PTSD, a second by Roberts and colleagues looked at early therapeutic interventions soon after the traumatic event, and finally a meta-analysis by Ifigeneia Mavranezouli and her team in London looked at the relative effectiveness of different treatments for children and young people with trauma-related distress.
What works for Complex PTSD? A meta-analytic review of 51 research studies by Thanos Karatzias and his colleagues and published in Psychological Medicine tried to answer the question: What does the evidence say about which psychotherapeutic interventions work for complex PTSD? Looking only at well-designed studies, and working with universities around the world in Edinburgh, Cardiff, California, Zurich and elsewhere, the study concluded that Cognitive behavioural therapy (CBT), exposure alone (EA) and eye movement desensitisation and reprocessing (EMDR) were superior to usual care for PTSD symptoms-with CBT proving more effective than EMDR. Both CBT and EA each had a noticeable effect on negative self-concept. Unfortunately only one trial of EMDR provided useable data for the meta-analysis. This is often the case with EMDR, where there are insuffcient number of properly-designed and excuted studies to enable robust conclusions to be drawn on its effect. On the basis of the analysis of the relevant studies, the authors concluded that CBT, EA and EMDR each had moderate or moderate-large effects on disturbed relationships. The benefits of all interventions were smaller when compared with non-specific interventions (e.g. befriending). Statistical analysis which removed the impact of biasing factors highlighted that childhood-onset trauma, rather than onset in later life was associated with a poorer outcome.
What works for early interventions for PTSD? Another meta-analytic review published in 2020 in the European Journal of Psychotraumatology by Neil Roberts and his team at Cardiff which looked at the current best evidence regarding early therapeutic interventions designed to prevent or treat traumatic stress symptoms within three months of expoosure to trauma. They found that for individuals reporting traumatic stress symptoms there were clear benefits of trauma-focused cognitive-behavioural therapy (CBT-T), cognitive therapy without exposure and eye movement desensitization and reprocessing (EMDR). Differences were greatest for those diagnosed with acute stress disorder (ASD) and PTSD. Overall, evidence was strongest for trauma-focused CBT as being effective.
What works best for children and young people? In a review of 32 high quality studies of 17 interventions and 2,260 participants published worldwide, Ifigeneia Mavranezouli and her team from University College London tried to determine what the best evidence available tells us about different therapeutic interventions for trauma affecting young people and children. They found that trauma-focused cognitive behavioural therapy appeared to be most effective in the management of PTSD in youth. Once again EMDR was also found to be effective but to a lesser degree. Interestingly, they found that supportive counselling does not appear to be effective. Overall, they found a large helpful effect for the emotional freedom technique, child–parent psychotherapy, combined TF-CBT/parent training, and meditation. But they highlight that the evaluations of these specific interventions need further research as they were based on “very limited evidence”. The effectiveness of TF-CBT and EMDR was based on a much wider evidence base, however.
Overall, then these three studies, each looking at a distinctive aspect of PTSD and trauma-related distress, find that CBT or a variant of CBT such as TF-CBT, is the most effective treatment for PTSD and related areas. EMDR has also been found to be reliably effective, but the effect is not so strong and the evidence base is not as broad as that for CBT. Some of these reviews that effectiveness of various interventions can be maximised when combined with other techniques. The Mavranezouli review of interventions for children and young people suggests the impact of supportive counselling alone may not be enough to help.
How does this all impact of clinical practice? Overall, it is clear that CBT remains a powerful therapeutic approach to the treatment of trauma – but that EMDR, which is still perceived as controversial in several quarters, does have evidence of effectiveness.
If you would like to explore more issues in PTSD including practical techniques and approaches, based on established protocols you can sign up for one of our 2-hour live online CPD webinars. The webinars explore the practical side of CBT and related approaches to treating PTSD.
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References
Karatzias, T., Murphy, P., Cloitre, M., Bisson, J., Roberts, N., Shevlin, M., . . . Hutton, P. (2019). Psychological interventions for ICD-11 complex PTSD symptoms: Systematic review and meta-analysis. Psychological Medicine, 49(11), 1761-1775. doi:10.1017/S0033291719000436
Roberts, N. P., Kitchiner, N. J., Kenardy, J., Lewis, C. E., & Bisson, J. I. (2019). Early psychological intervention following recent trauma: A systematic review and meta-analysis. European Journal of Psychotraumatology, 10(1), 1695486. doi:10.1080/20008198.2019.1695486
Mavranezouli, I., Megnin‐Viggars, O., Daly, C., Dias, S., Stockton, S., Meiser‐Stedman, R., . . . Pilling, S. (2020). Research review: Psychological and psychosocial treatments for children and young people with post‐traumatic stress disorder: A network meta‐analysis. Journal of Child Psychology and Psychiatry, 61(1), 18-29. doi:10.1111/jcpp.13094
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