Adverse Effects of Trauma-Focused Therapies (Part 2)

By Louise Gaston, Ph.D., FAIS

This is an article from the Fall 2020 issue of Combat Stress

In Part 1, I presented how the most popular trauma-focused therapies (TFT) for PTSD can induce adverse side effects (iatrogenic effects), even though these are very rarely reported by researchers.¹ In Part 2, I describe the adverse side effects of TFT as they were reported to me by my colleagues and by professionals who attended my courses on PTSD. In addition, I provide clinical descriptions from my own clinical experience. With ample clinical evidence, the objective of Part 2 is to illustrate the findings of studies reported in Part 1. I wish to reveal a sad and sometimes disturbing reality to invite clinicians to exercise caution in treating PTSD with trauma-focused therapies.

The most popular TFT are the following: prolonged exposure (PE), Eye Movement Desensitization and Reprocessing (EMDR), and Cognitive Processing Therapy (CPT). This article will focus on the adverse side effects of these techniques. To my knowledge, these TFT are not equally practiced by clinicians; along with CPT, PE appears to be mostly employed by professionals at governmental clinics or hospitals for Veterans, while professionals in private practice seem to mostly employ EMDR.  Despite their popularity, these TFT can induce adverse side effects.

As presented in Part 1, these TFT were shown by researchers to be efficacious for 50% of civilians and 33% of military personnel and Veterans, by reducing the PTSD symptomatology to a loss of diagnosis but without fully remitting the PTSD.¹ In clinical trials, participants are highly selected by researchers, including only individuals suffering from simple PTSD, without co-morbidity. Therefore, it is fair to say that these TFT can only be helpful for some people presenting with PTSD, those without co-morbidity, and willing to undergo a TFT. However, what happens to those who do not fit the selection criteria, are not helped, or are not compliant? Most Veterans fit this profile in the real world, and they need personalized treatment.

In the real world, people tend to be different from the world of clinical research; they are more complex. In the real world, few Veterans and civilians with PTSD fit the selection criterion applied in research, and only a minority truly benefits from TFT.  They are not the ideal patients suited for manualized treatments.

Indeed, a colleague of mine reported that all her Veterans in psychotherapy know at least another Veteran who committed suicide after TFT. To verify if this reality could be pervasive, I asked another one of my colleagues who treat a lot of Veterans with PTSD, and, unfortunately, she had the same story; all Veterans knew at least one Veteran who had committed suicide after TFT. Sadly, I once challenged a professional working at a Veterans’ clinic regarding their systematic use of TFT, and the answer was, “Well, Louise, we have helped one guy!”

Below, the testimonies shared by some colleagues vary greatly in length. I have reported them as they were sent to me, as much as possible although I had to shorten most of them. The testimonies describe many adverse side effects induced by popular TFT. Some colleagues also wished to describe the reparative effects of integrative psychotherapy for PTSD, one tailored to the needs and capacities of each person.

PE’s Adverse Side Effects

Before I present a few testimonies on the adverse side effects of PE, I would like to mention that, in the early ‘90s, I took training on PE offered by Edna Foa, the main proponent of the use of PE for treating PTSD. After this training, it was clear to me that PE was counter to my ethical and theoretical understanding of both PTSD and psychotherapy. Let us remember that PE was previously called ‘flooding’ or ‘immersion,’ but it was renamed ‘prolonged exposure’ by Foa. Let’s also remember that Joseph Wolpe, the originator of flooding, tested the efficacy of flooding by forcing a young girl, who was afraid of being in a driven car, to spend 9 hours in his car while he was driving.

Professional’s Testimony 1. “A new patient of mine experienced severe deterioration after the use of PE for very violent traumas. At 13 years old, she had been repeatedly raped, almost strangled, and threatened by her boyfriend that he would kill her mother and father. PE was applied by the previous therapist following the recommendation of her treating physician. The deterioration was psychological disorganization, with self-mutilation, guilt, and shame.”

Professional’s Testimony 2. “I had a Veteran as a client in evaluation for PTSD. He was receiving a second round of PE because the first one did not yield any effects. The clinician had told him that the process had to be repeated because it did not work the first time. The second round worsened the Veteran’s anxiety to the point that he became suicidal. Since when has redoing something ineffective the first time become a ‘good’ professional practice?”

Professional’s Testimony 3. “A correctional officer at a prison was severely attacked by inmates and developed extreme PTSD. Within the context of integrative psychotherapy with me, his symptoms ameliorated. However, his treating physician insisted that he exposed himself to his main PTSD trigger, namely the prison in order to prepare himself to go back to work. Against my recommendations, he dutifully exposed himself. During the exposure, he vomited violently and, afterward, his homicidal and suicidal ideations came back forcefully, along with precise plans. The homicidal plans are still present, although abated, after one year.”

Professional’s Testimony 4. “I have been seeing a Veteran in psychotherapy for over a year and a half. He was previously treated at a Veterans’ clinic for 2 years for his PTSD, chronic pain, and alcohol abuse. Cognitive-behavioral therapy with TFT was applied. Although he informed the psychologist many times that his treatment impacted him negatively, she continued to apply exposure therapy. When the Veteran became disorganized, the treating psychologist finally abdicated and referred him to me. Nonetheless, in her referral notes, she still recommended in vivo exposure to public places, even though these are post-traumatic reminders to this Veteran. This Veteran was traumatized in two ways: (1) a very severe PTSD due to military missions and (2) a heightened fear about any techniques that a psychotherapist could impose upon him in a seemingly benevolent context.

He also presented with dissociative symptoms (derealization and dissociative flashbacks) and was extremely anxious throughout the day. In our first sessions, I prioritized the cessation of his own spontaneous exposures to post-traumatic cues and I offered him calming and re-associative techniques. His dissociative symptoms quickly abated.”

Professional’s Testimony 5. “A Veteran, who was a hero in Afghanistan, consulted me for a refractory extreme PTSD, accompanied by a chronic shaking of hands. At the VA hospital, he had undergone three series of PE over 5 years. Subsequently, he developed hypertension. At first, I tried systematic desensitization, but it did not help, so I decided to opt for long-term integrative psychotherapy. Success! His PTSD has been in remission for a few years now.”  

EMDR’s Adverse Side Effects

In 1995, I attended a three-day training given by the originator of EMDR, Francine Shapiro. When I subsequently tried EMDR with a few patients, adverse side effects emerged: manic flight of ideas statements repeated in a loop (i.e., ‘I don’t know!’), painful somatic reactions including sharp bodily pains, migraines, nausea, and anger or contempt toward the technique. Consequently, I ceased to employ EMDR to prevent iatrogenic effects.

From 1997 to 2007, I gave continuing education courses on PTSD across the USA. Some attendees shared with me the adverse side effects reported by their new patients who had undergone EMDR, and I took notes. The adverse side effects were diverse: partial facial paralysis, intense vomiting for days, severe loss of motivation, alcohol and drug relapse, panic attacks, severe self-mutilation, suicide attempts, and psychotic breakdowns. When patients reported these adverse side effects to the EMDR therapists, they consistently responded with statements implying that the effects could not be due to EMDR because it produces only temporary side effects such as traumatic reminiscences. Obviously, the patients’ damaging experiences countered the therapists’ rebuttals. Below are some testimonies shared by my colleagues regarding the adverse side effects experienced by their patients; people who had been previously treated with EMDR.

Professional’s Testimony 1. “A patient of mine was previously forced by the workers’ compensation agency to consult an EMDR therapist. At the eight-session, he had a panic attack so intense that he ended up lying down on the floor. The therapist did nothing to help him or to assist him to recollect himself. Instead, he let him go away and drive away in his car.”

Professional’s Testimony 2. “I heard a well-known comedian reporting on the radio that he became blind for a few weeks after the use of EMDR.”

Professional’s Testimony 3. “A client of mine consulted an EMDR therapist who used this technique with her in a repetitive fashion. The patient did indicate clearly to the therapist that she did not like EMDR. Within the next 6 months, she attempted suicide three times, all requiring psychiatric hospitalizations. Nonetheless, the EMDR therapist persevered in using EMDR. This 40-year-old woman presented with a borderline personality disorder, but she had ceased all suicide attempts since she was 16 years old. Since the beginning of an integrative dynamic therapy over a year ago, this woman has not attempted to end her life anymore. She is now almost symptom-free and is back at work.”

Professional’s Testimony 4. “This report is about a 29-year-old woman, without children, who holds an executive position in a large company. We have had about 25 sessions so far. She sought psychotherapy for incest perpetrated by her father during her childhood and adolescence. Previously, she had EMDR for 4 months, which provoked adverse side effects. In our first session, she explained to me that, during EMDR therapy, she had felt overwhelmed with anger and that her personal and marital difficulties had been getting worse. She felt a lump in her throat and ready to explode. Her condition was getting worse.

After 6 months of integrative psychotherapy, I asked her to describe the TFT process of EMDR in comparison with the integrative psychotherapy with me. She explained that, in EMDR, it was difficult because she had to describe what happened to her. She felt she had to “dive in” without understanding the process or the possible benefits. She specified that the major difficulty was that there was no established relationship of trust between her and the therapist. At each session, she felt a rising anger, which she had to rate on a 10-point scale according to the EMDR therapist. She felt a ball suffocating her in her stomach. She reported no positive impact from this TFT. On the contrary, during the winter, she remembers the ‘worst episode of everything,’ namely, an overwhelming depressive state with suicidal ideation. She sought to free herself from this weight and despair. She turned her anger toward the therapist, challenging her. This was liberating for her, but it was also accompanied by an unbearable feeling. Her rage precipitated her to search for another therapist, another approach, which led her to consult me.

With our integrative work, she reports that her anger has become more and more diffused, instead of oppressing and inhibiting her. She feels respected by me in her abilities and steps. The emphasis is now placed on the therapeutic relationship, the working alliance is central. Our gradual exploration of her traumas respects her rhythm because she feels that she can explore them freely and is better able to tolerate suffering. She can trust that this fight is no longer directed against herself and she positively anticipates revisiting her traumas gradually.”

Professional’s Testimony 5. “This story is about a man in his 30s who was responsible for the death of his girlfriend through negligence on his part during the practice of an extreme sport. He initially consulted an EMDR therapist. At the end of the EMDR therapy, he no longer had emotion-laden recurrent memories of the accident. Nonetheless, 2 years later, he became increasingly destabilized, with disturbing and vague emotional pressure.

When he first consulted me, he reported feeling like a volcano, ready to erupt. This inner pressure was caused by rage. He was highly fearful of lashing out in angry outbursts. He was frantic and destabilized, not knowing what to do or think about all this and his life. He was very suspicious toward me, sarcastic, and contemptuous – constantly testing our relationship. He was at odds with himself; he wanted to be relieved from his inner tension, but he was unable to trust me. Establishing an alliance required a lot of attention, oscillating between addressing the trauma cognitively and his daily functioning. After months, he started to be emotionally stable and he trusted me. His defense mechanisms were attenuated. Our increasing understanding of his trauma and the attenuation of his distress gave him a greater sense of control. After several months, he eagerly anticipated the next therapeutic stage, namely the one involving the re-experience of the trauma via introspective hypnosis. His dreams gave him signs that he was ready to experientially revisit the traumatic event to an emotional level.

Here is a dream which was a turning point. He walks with a sports jacket (associated with the accident) towards a body of water. He thinks that it is a tiny puddle. As he walks into the puddle voluntarily, he realizes that he is falling into a deep body of water. At first, he wants to get out and struggles, but he then stops fighting and surrenders to the experience.

After this dream, he was ready to deeply address the accident, along with his character issues. With this newly found attitude, his PTSD reemerged forcefully, confirming that the EMDR therapy had not resolved the trauma, but most likely induced emotional inhibition. Within integrative psychotherapy, we worked on his childhood-based issues (including his anger toward his mother who abandoned him as a child), which allowed him to acknowledge his vulnerability and needfulness. After a couple of years of psychotherapy, his PTSD completely remitted. He did not have to re-experience the traumatic event because deep character issues were resolved.

He now knows that he can take care of a vulnerable person without becoming unconsciously destructive and he can trust others to be there for him most of the time. Upon termination, he reported that the integrative approach gave him much more than focusing on the trauma. He now knows that his whole person was involved in this tragic accident.”

Professional’s Testimony 6. “I have a colleague who practices EDMR and hypnosis in the short-term (six sessions). He refers patients to me with PTSD who need follow-up psychotherapy after he applied EMDR.  When these patients arrive in my office, they are very often in a state of crisis. The analogy of the ‘downward spiral’ illustrates well the descriptions of their psychological state.”

CPT’s Adverse Side Effects

I learned about CPT by assisting in a presentation given by its originator, Patricia Resick. I have never used it or taught it. I do not trust that persons with severe PTSD can safely write down the description of their traumatic experience, alone at home, while re-experiencing the trauma emotionally as much as possible. CPT proponents have not reported adverse effects from the use of this TFT. However, clinical reality reveals a different story.

Professional’s Testimony 1. “Many years ago, at the beginning of my practice when I was employing cognitive-behavioral therapy, I saw a young woman who had recently been raped. She presented with a borderline personality disorder and complex PTSD. Her mother was a substance abuser and her father was disengaged and criminalized, which led her to be placed in many foster homes as a child. She ended up working as a prostitute and was raped in this context. We started therapy by using traditional cognitive techniques. Given that she could not describe the rape in detail in my office, I asked her to expose herself to this traumatic experience, by herself at home, by writing it down with as many details as possible and to re-experience the emerging emotions. At our next session, she was beside herself. At home, she had started to write down her experience of the rape, but she could not finish because she had become emotionally overwhelmed. The ensuing disorganized state led her to throw all the furniture she could lift out of the window of her second-floor apartment. She violently lost control in front of her 2-year-old child.”

Professional’s Testimony 2. “I saw in psychotherapy a woman Veteran in her early thirties. Before the Army, she had experienced childhood traumas within the context of an extremely negligent family (e.g., just a few clothes, parents consuming and selling drugs, etc.). She had attempted suicide at 15 years old. She developed PTSD from a mission in Afghanistan. Upon her return, her spouse (another soldier) cheated on her with a recruit and all her colleagues knew about it, which triggered a crisis accompanied by a major depressive episode and an exacerbated PTSD. Throughout psychotherapy, her physical health deteriorated, along with her physical pain. She polarized her clinical team. She also repeatedly asked her physician to relieve her pain with morphine. In response, her clinical team put pressure on me to use TFT. I accepted and applied CPT, which caused symptomatic deterioration and abandonment of therapy.”

Conclusion

My colleague who described a successful long-term integrative psychotherapy with a Veteran (PE-Professional’s Testimony 5) added valuable comments. I wish to conclude with his words:

“Here is an update. I recently heard from the Veteran who had a 5-year series of PE. He is very happy, still works, and has created a small sideline for fun. This success story is an example of beautiful complicity between a psychiatrist, who finds the right molecule, and a psychologist who applies psychotherapy which makes sense, promoting the integration of the traumatized self into the pre-existing self. For him, it became clear that his high blood pressure problems began with the PE series. He understood that he had to get the right medication to become psychologically available to the psychotherapeutic process aiming at integrating his trauma to his whole self. After this insight, everything unfolded quickly. He has done a titanic job of changing his pre-existing self, clarifying, and dissecting his anxiety as an emotional complex, and allowing himself to isolate his anger from associated emotions.

From this psychotherapy, it is now clear to me that anger is always present in anxiety associated with PTSD. If we identify its purpose, it allows us to clarify the other associated emotions and identify their aims as well. After that, sadness always emerges, and empathy comes along. Unlocking empathy toward others and oneself in someone with a narcissistic covert frame (not a disorder) is like finding the El Dorado. It is so beautiful.

The turning point in the process was the resolution of a therapeutic impasse. Without this impasse, this Veteran would have kept the same attitude, one of someone determined to obey any instructions. It was because we worked on the therapeutic relationship that we were able to change this impasse into a trajectory effecting change. Without this pause and feedback on his compulsive issues at helping others, progress would not have taken place. It was in a dialogue about the very dynamics of his therapeutic choices, along with the emerging uncertainties, that the client trusted me even more because he realized that the therapeutic process was the scene of his own internal impasse, which he had been feeling for more than 10 years. What was reassuring, as he told me later, is that I would take full measure of his dismay and said to him, “I don’t have the answers now, but I’m looking.” Suddenly, something happened in him. He was no longer alone. He was working with his psychologist and his psychologist was working with him, without complacency, in search, in doubt, with the burden of uncertainty, in humility, without a ‘scientific posturing,’ without an ‘expert’ who conveys that he works badly if he does not feel better. … He realized that, at the very moment when we had the greatest number of questions and fewest answers, his psychologist was confident anyway! He could finally settle down and trust without having to control everything.

The secret is that there are no two psychotherapeutic processes that are the same. Each psychotherapy has its own peculiarities. The response plan must be tailored to the inner dynamics of every individual. Psychotherapy cannot be standardized, preformatted. This is indeed magical about psychotherapy: in every session, we never know what is in store. This realization forces us, psychotherapist, to remain humble and attentive. It keeps the job interesting and keeps us awake and alert. In contrast, psychotherapists who have a rigid and preformatted therapy plan seem to be missing something. Isn’t this a little sad?”

At my clinic, we employ an integrative approach for treating PTSD. This integrative psychotherapy is tailored to the needs and capacities of each person. No TFT is forced upon a patient. At times, it may be suggested to use a particular TFT to access meaningful information about the traumatic experience and re-associate its various elements (e.g., affects, cognitions, appraisals, sensations, etc.). A TFT called ‘introspective hypnosis’ is employed, if and only if several prerequisites are met: (1) such a technique may yield meaningful information to resolve the PTSD; (2) the person is stabilized, namely, not overwhelmed symptomatically and adequately functioning; (3) a therapeutic alliance is well-established; (4) the person demonstrates an obvious capacity for emotional regulation; and (5) the psychotherapist has a solid understanding of the person’s intrapsychic and interpersonal worlds. During the TFT, we proceed gradually, which allows us to identify any potential sign of destabilization and to intervene consequently. The person remains in control of the process, having the freedom to ask to cease the technique at any given moment. The therapist supports and guides by inviting the person to attend to the experience and then reflect upon it, back and forth. Over the last 30 years, no patient has been destabilized by this approach. From 100 of our files randomly selected, an independent researcher found a 96% rate of PTSD remission.² This integrative psychotherapy for PTSD is tailored to the needs and capacities of each person and it works.

References

1. Gaston, L. (2020). Adverse Effects of Trauma-Focused Therapies (Part 1). Combat Stress, Summer, 40-47.
2. Brunet, A. Pilot study for a grant submission on the neural correlates of PTSD changes in psychotherapy. Unpublished report, Department of Psychiatry, McGill University, Douglas Institute, 6875 boul. LaSalle, Montreal (Quebec), Canada H4H 1R3.

ABOUT THE AUTHOR

Dr. Louise Gaston, a psychologist, has founded in 1990 a clinic specialized in PTSD, TRAUMATYS, in Canada, where she developed an integrative model for treating PTSD, which is flexible and open-ended. In addition, she elaborated a comprehensive 2-year training program in PTSD and trained more than 200 experienced clinicians in evaluating and treating PTSD. Thousands of individuals presenting with PTSD and comorbidity have been treated with this integrative model for PTSD. According to an independent and retrospective study, the associated PTSD remission rate is 96%: 48% complete and 48% partial. Dr. Gaston is the author of several book chapters and more than 40 scientific/clinical articles.

Since 1980, Dr. Gaston has been practicing psychotherapy. She has been trained and supervised for over 15 years. She knows all major models of psychotherapy (dynamic, humanistic, cognitive, and behavioral) and has been trained for over 5 years in treating personality disorders.

As a clinical researcher, Dr. Gaston collaborated with many colleagues in diverse settings. She has carried out two clinical trials. Her main research topic was the alliance in psychotherapy and its interaction with techniques as they contribute to better outcomes. In collaboration with Dr. Marmar, M.D., she has developed the California Psychotherapy Alliance Scale, CALPAS, a measure of the alliance in psychotherapy that is worldly used.

In 1988, Dr. Gaston completed a 2-year postdoctoral fellowship in PTSD and psychotherapy research, at the Langley Porter Psychiatric Institute, University of California, San Francisco, under the supervision of Dr. Horowitz, M.D., author of Stress Response Syndrome, and Dr. Marmar, M.D., both ex-presidents of the International Society for Psychotherapy Research and the International Society for Traumatic Stress Studies. Afterward, she was an assistant professor in the Department of Psychiatry at McGill University in Canada from 1988 to 1994. Dr. Gaston elaborated scales on the MMPI-2 to assess PTSD in civilians.

For many years, Dr. Gaston has provided courses of continuing education across the USA: Integrating Treatments for PTSD, Trauma and Personality Disorders, Memories of Abuse and the Abuse of Memory, and Ethics Working for You. Nowadays she writes, trains, and supervises on PTSD.

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