Problems With New American Evidence-Based Guidelines For Therapy With Survivors of Trauma.

I have a special interest in psychological trauma and its treatment. I was reading this article in Psychology Today by Jonathan Shedler, a clinical professor at the University of Colorado School of Medicine. This article has been doing the rounds in various professional circles this week and I thought it was interesting enough and accessible enough to share here. Basically, he is highly critical of the new guidelines issued by the American Psychological Association for treating people with posttraumatic stress disorder (PTSD) and other types of psychological trauma. The new guidelines recommend that therapists use brief forms of trauma-focussed cognitive behavioural therapy (CBT), that are highly manualised. The recommendations were developed based on randomised controlled trials (RCT's) of psychological therapy with patients conducted over 16-week periods. Shedler asserts that because RCT's are the only type of study looked at, they ignore other forms of evidence available. In fact he is even so critical to argue that in many other areas of science (particularly the hard sciences of chemistry, biology, and physics) do not place such heavy reliance on RCT's. RCT's are often looked at as the "gold standard" in psychology for psychological treatment outcome studies. He argues that in many other areas of science RCT's have not been relied upon to provide important evidence regarding things we now take for granted and provides some compelling examples. One major problem that Shedler has identified with this approach of limiting research to only brief CBT, is that there is considerable evidence to show that (especially in the case of persons with significant psychological trauma) psychological therapy is "dose responsive", in that it takes time for people to get better. Generally, it takes at least 20 sessions or six months of weekly therapy before half of patients show any meaningful improvement in psychological functioning and about 40 sessions of weekly therapy before approximately 75% of people show any meaningful improvement. His criticism is that given the studies that have been relied upon are of only 16-weeks duration or less, they are essentially studying therapy that is of inadequate duration, especially in the case of psychological trauma. Shedler argues that the new guidelines seem to be driven more by economic concerns, rather than what is best for patients. He also cites some significant problems associated with relying exclusively on evidence collected from RCT's. Shedler observed that in many of the best studies that have been used to study brief forms of CBT for trauma, most of the patients did not get any better. Another interesting finding is that at least half of the patients dropped out of treatment in these studies; about 60% of patients still had PTSD at the end of the 16 sessions of treatment; and all of them were still clinically depressed at the conclusion of these studies. Additionally, when patients were assessed six months later they were no better than the patients who were assigned to a control condition. He further argues that many successful longer-term therapies have been excluded from the guidelines and provides some further critique of the guidelines along with some general well-established principles in the treatment of psychological trauma. It all makes for some very interesting reading. I have provided a link to the article below.