Evidence Based Treatment of PTSD
The Department of Defense medical services and the VA medical system have taken the position that veterans with PTSD should be treated with “evidence-based treatment methodologies”. While the regulations are working to keep ineffective cures out of the VA, it has imposed a 10- to 15-year certification process, before the much needed, new and more effective treatments can be certified as evidentiary medicine and put to use. Following, is a referenced description of three approved therapies for PTSD and the new RTM Treatment currently being researched for approved VA use. (Therapies for anxiety and depressive disorders centered on Cognitive Behavioral frameworks are some of the most heavily researched and validated therapies. Over the last 60 years these approaches have been refined and compared with many other forms of treatment such as psychopharmacology, classical behavioral therapy, and psychoanalysis.)
Three specific approaches approved to treat soldiers diagnosed with PTSD are Prolonged Exposure Therapy (PE), whose development was spearheaded by Edna Foa, Cognitive Processing Therapy (CPT), developed by Patricia Resick, PhD, and EMDR, developed by Francine Shapiro, PhD. A brief summary of these approaches follows as does a descriptions of NLP approaches.
Cognitive Processing Therapy
Cognitive processing therapy. CPT (Resick, 2001a) is a manualized, 12-session, specific form of CBT for PTSD that has a primary focus on cognitive interventions. The initial session of CPT is psycho-educational; the symptoms of PTSD are explained within a cognitive and information processing theory (Lang, 1977) framework. At the conclusion of this initial session, patients are asked to write a “statement.” The statement includes writing about the meaning of the traumatic event, as well as beliefs about why the event happened. The impact statement is read and discussed in Session 2, with an eye toward identifying problematic beliefs and cognitions (“stuck points”). Patients are then taught to identify the connection between events, thoughts, and feelings and to practice this as homework. Session 3 includes a review of the self-monitoring homework and patients are instructed to write a detailed account of their most traumatic event at home and to read it every day prior to Session 4. When there are multiple experiences of trauma (as in the majority of cases), patients write about the “worst” experience, particularly the one that is related to intrusive symptoms. The goals of Sessions 4 and 5 are to recall and better contextualize traumatic events and to experience the natural emotions that they may have suppressed following these events. CPT includes exposure to the traumatic memory through writing and reading accounts, with a focus on feelings, beliefs, and thoughts that emanated from the traumatic events. At the conclusion of Session 4, patients are asked to rewrite the trauma account with more details and emotions and to document their current thoughts and beliefs as they write the account. They are also asked to read the new account daily prior to Session 5. In Session 5, patients read the second account, and the therapy transitions to cognitive challenging. Using a Socratic style of questioning, the therapist teaches patients to ask questions regarding their assumptions and self-statements in order to begin challenging them. Patients are taught in Sessions 5, 6, and 7 how to use worksheets in their day-to-day lives to challenge and modify maladaptive thoughts and beliefs related to their traumatic experiences. In the final five sessions, over-generalized beliefs in five areas (i.e., safety, trust, power/control, esteem, and intimacy) are challenged as they relate to self and other. Treatment gains are consolidated in the final session. (Monson, Schnurr, et al., 2007, p 898-907)
Prolonged Exposure Therapy
“In prolonged exposure PE, a patient is asked to vividly recount a traumatic event repeatedly until the patient's emotional response decreases and to gradually confront safe but fear-evoking trauma reminders. Prolonged exposure is delivered in 10 weekly, 90-minute sessions according to a manual that specified the content and structure of each session. Prolonged exposure included education about common reactions to trauma; breathing retraining; prolonged (repeated) recounting (imaginal exposure) of trauma memories during sessions; homework (listening to a recording of the recounting made during the therapy session, and repeated in vivo exposure to safe situations the patient avoids because of trauma-related fear); and discussion of thoughts and feelings related to exposure exercises. Sessions 1 and 2 were introductory, and included provision of the treatment rationale and education about PTSD. Imaginal exposure occurred in sessions 3 through 10. Exposure is used to enhance emotional processing of traumatic events by helping patients face trauma memories and situations associated with them. Patients learn to distinguish memories and associated situations from the event itself. They also learn they can safely experience reminders and tolerate any resulting distress and that distress decreases over time. The focus in prolonged exposure can be a single event or multiple events. In the latter case, the therapist establishes which memory will be the focus of imaginal exposure — the most distressing memory. Successfully processing the most distressing memory usually generalizes to other memories. If another event still triggers significant distress, imaginal exposure is then used with that memory. Sometimes confronting feared situations or memories triggers urges to escape or avoid. When this occurs, the therapist acknowledges the patient’s feelings, reminding the patient that avoidance reduces anxiety in the short term but maintains fear and prevents learning that the feared situations or memories are not dangerous. The therapist also breaks exposure into a more gradual progression.”
(Monson, Schnurr, et al., 2007, p 898-907)
EMDR
Francine Shapiro, the developer of EMDR, worked for a number of years for one of the co-founders of NLP. The technique is believed by many NLP experts to be a protocol that evolved directly from basic NLP practices. It consists of an elicitation of the traumatic experience in various forms as the client is led through a series of programmed eye-movements. Evidence supporting its effectiveness was initially done with single memory traumas and showed large effects including 84% cessation of all symptoms that remained stable through a six-month follow-up (this is contrasted against 20% to 50% effectiveness of PE and CPT when one includes dropout rates in calculations for those treatments) (Barerra, Mott, et al., 2013; Bisson & Andrew, 2007; Goodson et al., 2011). The efficacy of EMDR has recently come into question as studies conducted to replicate the early findings were not consistently able to do so. The follow-up studies were often run with multiple traumas and with clinicians trained at one of the many EMDR training centers around the country. Poor quality control at these Training Centers has been pointed to as a possible cause of the problem but its validity continues to be re-evaluated. Other studies, separating the eye-movement components from the rest of the protocol have found no change in its efficacy, thus calling into question the value of its distinctive eye- movement patterns. In general, multiple evaluations of EMDR in recent years have found that on average, it produces results no different from other cognitive behavioral interventions. There is ongoing discussion of its status as a bona fide treatment protocol.
NLP
With NLP, we pass to a set of interventions which has neither been recognized as a bona fide treatment nor subjected to the rigorous testing and replication studies that would qualify it as an evidence-based practice. Scientifically, validation research for Neuro-Linguistic Programming (NLP) is 10 to 15 years behind the research done on EMDR which, in turn, is two to four years behind PE and CPT. Given the aggressive scientific criticism and the slow medical acceptance of EMDR, we can expect similar difficulties with the introduction of NLP protocols into clinical practice. In contrast to EMDR’s single protocol, NLP has 20 to 30 treatment protocols such as the PTSD treatment protocol, Reconsolidation of Traumatic Memories (RTM), which is now entering clinical pilot studies. In contrast to a single ”recipe” applicable to treating phobias, NLP is a collection of skill training “packages” based upon the idea that all human experience consists of a series of perceptions and behaviors that represent the external behavior to internal experience. This brief review will focus on the RTM protocol which is in the pilot study stage.
The RTM protocol has shown efficacy in clinical use with PTSD. There is a large body of anecdotal and clinical evidence to support the practice, and a plausible neurological mechanism for its efficacy has been described (Gray & Liotta, 2012). Using the classification system put forward by Foa, Keane, and Friedman (2000), and Benish et al. (2010), the intervention can be classed as a trauma-focused cognitive behavior therapy (TFCBT), or more simply, an imaginal exposure therapy. However, where PE has the client fully re-experience traumatic memories as if they were happening again, a process that in another context would be called re-traumatization, the RTM protocol only allows a brief, non-traumatizing exposure at the beginning of treatment. Later, the client observes the traumatic event first, from the perspective of a glassed-in projection booth, watching another person, who is watching a movie of someone else experiencing the troubling event. After that task is accomplished, they re-experience the event in reverse at high speed. These two elements are non- traumatizing. When the memory is viewed in this way, the intense feelings of terror are separated from the experience itself, so this can be done comfortably, changing the nature of the experience for the client.
Treatment, as in CBT protocols, often consists in changing or challenging internal representations. Hence, the traumatic picture of a friend dying is dealt with as a separate and malleable representation of the original traumatizing event. The efficacy and distinguishing quality of NLP treatments is found in the understanding and use of these separate mental representations. For instance, having the ability to have a traumatized soldier alter the way he recalls a traumatic picture by turning off the feelings while recalling the traumatic picture, allows NLP to restructure the experience in a manner consistent with Lang’s (1983) position on the reconfiguration of memory. The result is perceived as “painless” because there are no bad feelings, and quick because repetitions of the “phobic” picture can be done at the speed of thought. Over years of clinical use, NLP has evolved effective protocols by experimenting with alterations in mental representations. These protocols need to be researched before they can be legally accepted into clinical use by VA’s and Army caregivers. The RTM model, under multiple guises (including the V/KD protocol and the rewind technique) is supported by 25 years or more of anecdotal and clinical reports covering thousands of patients. Although only subject to three peer-reviewed evaluations in the last 25 years, each of the evaluations deemed it worthy of further investigation. One author, Muss, has continued using the technique and through his efforts it is now a recognized treatment for PTSD in the UK (Carbonell & Figley, 1999; Dietrich, 2000; Koziey and McLeod, 1987; Muss, 1991, 2002; Utuza, Joseph & Muss, 2012).
More recently, Gray and Liotta (2012) have identified the effects of the RTM protocol with the now well-attested mechanism of memory reconsolidation, which changes the structure of emotional memories in a more or less permanent manner. By rewriting the emotional structure of the memory, the technique allows the beneficiary to reintegrate the traumatic event into a more normal narrative of their life.
Efficacy outcomes:
Despite their strong scientific base, evidence-based treatments often produce less than optimal results. Most results for such treatments are framed in terms of improvement in symptom scores as compared to control groups who either wait before being treated, or are treated with a program with limited or a known inability to produce meaningful changes. Against such treatments the evidence-based treatments can produce significant symptom reduction in about 50% of the test group participants. These results are regularly confirmed in meta-analyses of the evidence-based approaches.
Barerra, Mott, et al. (2013) examined 11 studies of group-based exposure therapies involving 651 subjects who reported for an average of 15 treatment sessions. After accounting for the 25% drop-out rate, they found a moderate effect size, meaning that about 50% of their subjects received benefit, none were cured.
Goodson et al. (2011) examined 24 studies that treated 1,742 veterans with PTSD using various evidence-based and other approaches, and reported that their subjects as a whole fared better than 66% of the untreated population. Again, this means that about 50% of those receiving the best treatments had improvements in their PTSD scores. Like the studies examined by Barerra et al., these treatments often averaged 15 visits, and again, there was no claim that the PTSD symptoms had been completely alleviated.
Strikingly, Bisson & Andrew (2007) in a Cochrane meta-analysis showed that most of the currently accepted treatments for PTSD whether evaluated singly or in combination, differed little from one another. All of them had low to moderate treatment effects and averaged out at providing assistance to about 50% of the treatment population.
The NLP-based RTM protocol, on the other hand, has a 25-year history in which case after case has shown complete alleviation of the intrusive, avoidant and hypervigilant symptoms of PTSD without recurrence in 75 to 85% of those treated. Unlike the treatments noted above, the RTM protocol can be delivered in four sessions or less and does not involve re-traumatization of the patient (Gray & Liotta, 2012; Gray & Bolsted, 2012). An illustrative case is reported by Utuza, Joseph, & Muss (2012). These authors reported using a parallel implementation (the Rewind Technique) with 28 survivors of the Rwandan Genocide, through a translator, with complete amelioration of symptoms at two-week follow-up.
Summary:
In general, outcome evaluations of CPT and PE protocols for PTSD indicate that approximately 50% of those treated experience some reduction of symptoms after completing these programs. The bad news is that 50% remain symptomatic. Drop-out rates can be as high as 40% for all evidence-based protocols. Most clients prefer the CPT approach. This preference is due to the unpleasant re-experiencing of the traumatic feelings required by the exposure approach of PE. At the same time, some of those dropping out actually report reduced symptoms on a level equal to those who completed treatment; but this has seldom been followed and can’t be quantified. Follow-up studies have not been able to quantify and answer all of the pertinent research questions at this time.
EMDR, while showing great promise initially, is mired in questions and doubts based upon failure to replicate its early positive results.
NLP stands at the beginning of the scientific process of clinical validation. The recent incorporation of the NLP Research and Recognition Project and the NLP PTSD research grants developed in cooperation with New York State, Bradley University, Emory University and The University of New Mexico, specifically constructed according to the RCT standard are concrete evidence of NLP’s commitment to empirical validation. In the three- to four-year interim before initial gold standard research can be published, however, the pressing clinical need and observable clinical performance, warrant measured clinical trials of the NLP PTSD treatment. We believe research into the NLP protocols will prove them effective, affordable, and teachable clinical treatments for problems such as PTSD.
References
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