Adverse Effects of Trauma-Focused Therapies (Part 1)
By Louise Gaston, PhD, FAIS
*This is an article from the Summer 2020 issue of Combat Stress.
Trauma-focused therapies (TFT) do induce adverse effects. Regrettably, this topic is highly neglected. We need to ask a crucial question: Are the limited benefits of TFT worth the risks of adverse effects? In this article, I present the adverse effects of the most popular TFT, namely, prolonged exposure (PE), Eye Movement Desensitization and Reprocessing (EMDR), and Cognitive Processing Therapy (CPT). The originators of these TFT claim that their therapies are not harmful. I disagree.
In any of these popular TFTs, participants with PTSD are asked to intensely relive what they spend most of their energy avoiding, that is, their highly emotional-laden traumatic memories. Given the neurobiological hypersensitivity associated with PTSD (especially in its severe form), the adverse effects of TFT can be severe, if not lethal by suicide. Although published reports of the adverse effects of TFT have been parsimonious, a scarcity of reports does not mean that adverse effects do not exist.
After three decades of research biased in favor of TFT, the American Psychological Association (APA) concluded that TFT are harmless and should be the first line of treatment for PTSD.1 In 2017, the APA’s committee on the clinical guidelines for treating PTSD wrote, “benefits outweigh harms/burdens, … there is no evidence that raises concern about applicability.” I disagree. This statement is scientifically committee must know it because they also wrote, “there are gaps in … measurement of potential side effects and harms, … and follow-up on reasons why participants leave a study.”1 How can such statements co-exist? How can the APA committee purport to present evidence-based guidelines for treating PTSD and, paradoxically, recognize at the same time that there is a lack of data regarding the adverse effects of TFT?
Unsurprisingly, the Veterans Administration (VA) has promoted and used these popular TFT for treating Veterans with PTSD. The VA website describes PE, EMDR and CPT as ‘talk therapies’ and claims that their risk corresponds only to “temporary discomfort.”2 I disagree. Enthusiastic conclusions about TFT are based on findings obtained in settings which do not reflect real-life conditions and exclude the majority of PTSD sufferers. These factors greatly limit the generalizability of findings. In addition, some research findings have been clearly distorted in favor of TFT, such as in a seminal paper by Foa et al.3 Even more concerning, most clinical trials have simply not considered the adverse effects of TFT.1
To understand the mainstream disavowal of adverse effects of TFT, it is important to acknowledge that there is a pervasive bias in researchers conducting the clinical trials funded by the PTSD Division of the National Institute of Mental Health. This bias is called ‘research affiliation’ and involves the fact that the efficacy of TFT has been evaluated by TFT proponents, which is problematic.1 In a science, a hypothesis is considered to be confirmed only if it has been tested by ‘opponents.’ Whenever opponents have examined the efficacy of TFT, serious adverse effects4, 5 and severe PTSD deteriorations6 were reported. Moreover, two surveys reported that PTSD experts and clinicians rarely employ PE due to a high drop-out rate and frequent adverse effects.7,8 Are researchers and policy makers paying any attention? Apparently, no.
The problem of adverse effects is so pervasive that Barlow, the main originator of exposure therapies for anxiety disorders, wrote a seminal paper aimed at warning the mental health community. He invited clinicians and researchers to take a closer look at the reality of adverse effects.9 Has anyone paid attention? Apparently, no. TFTs are still highly promoted by professional associations and governmental agencies, even if they can induce adverse effects. To better understand the occulted reality of adverse effects induced by TFT, let’s look at adverse effects reported by researchers and individuals.
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Prolonged Exposure (PE) PE proponents have ongoingly suggested that adverse effects from PE are quasiinexistent. Indeed, Foa et al. concluded that only a negligible number of PE participants exhibited PTSD exacerbations.10 Others disagree. In an honorary paper, Wampold et al. reanalysed their data and found substantial PTSD deteriorations from PE occurring after only one session.5 These non-proponents of PE concluded that PE should be deemed harmful. I agree.
In controlled clinical trials, adverse effects of PE were indeed reported. Pitman et al. found that 30% of PE participants developed a variety of adverse effects: depression, suicidal ideation, drug/alcohol relapses, panic attacks, and premature termination.11 Schnurr et al. reported a suicide attempt due to PE.12 Tarrier et al. observed PTSD deteriorations due to PE while none were observed in the non-TFT therapy.13
Beyond research reports, personal testimonies are crucial to really understand the adverse effects of TFT. So, let’s look at a poignant and telling story. In his book entitled The Evil Hours, an ex-Marine, David J. Morris, wrote about the severe deteriorations he experienced from PE.14
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“My therapist instructed me to select a traumatic event to focus on. … To focus on a single event seemed absurd, the equivalent of fast-forwarding to a single scene in an action film and judging the entire movie based on that. In the end I chose the story of the I.E.D. ambush I survived in 2007 in southern Baghdad.
Over the course of our sessions, my therapist had me tell the story of the ambush dozens of times. I would close my eyes and put myself back inside the Humvee with the patrol from the Army’s First Infantry Division, back inside my body armor, back inside the sound of the I.E.D.s going off, back inside the cave of smoke that threatened to envelop us all forever.
It was a difficult, emotionally draining scene to revisit. This was the work site of prolonged exposure therapy, where the heart’s truest labor was supposed to happen. Given enough time and enough story “reps,” when I opened my eyes again, I wouldn’t feel forever perched on the precipice of a smoke-wreathed eternity. I wouldn’t feel scared anymore.
But after a month of therapy, I began to have problems. When I think back on that time, the word that comes to mind is “nausea.” I felt sick inside, the blood hot in my veins. Never a good sleeper, I became an insomniac of the highest order. I couldn’t read, let alone write. I laced up my sneakers and went for a run around my neighborhood, hoping for release in some roadwork; after a couple of blocks, my calves seized up. It was like my body was at war with itself. One day, my cellphone failed to dial out and I stabbed it repeatedly with a stainless-steel knife until I bent the blade 90 degrees.
When I mentioned all this to my therapist, he seemed unsurprised. “You weren’t drunk at the time?” he asked. “No. That came later.” Following a heated discussion, in which I declared the therapy “insane and dangerous” and my therapist ardently defended it, we decided to call it quits. Before I left, he admonished me: “P.E. has worked for many, many people, so I would be careful about saying that it doesn’t work just because it didn’t work for you.”
Within a few weeks, my body returned to normal. My agitation subsided to the lower, simmering level it had been at before I went to the V.A. I began once more to sleep, read and write. I never spoke about the I.E.D. attack again.
… My own disappointment is that after waiting three months, after completing endless forms, I was offered an overhyped therapy built on the premise that the best way to escape the aftereffects of hell was to go through hell again.”
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I have nothing to add, except that the possibility of severe adverse effects induced by PE is not even mentioned on the website of the VA.15
Eye Movement Desensitization and Reprocessing (EMDR)
The EMDR Institute has only recognized temporary adverse effects from this technique. “As with any form of psychotherapy, there may be a temporary increase in distress: distressing and unresolved memories may emerge; some clients may experience reactions during a treatment session that neither they nor the administrating clinician may have anticipated, including a high level of emotion or physical sensation; and, subsequent to the treatment session, the processing of incidents/material may continue, and other dreams, memories, feelings, etc., may emerge.”16
However, severe adverse effects have been published.17, 18 For example, Brunet described how a Veteran with severe PTSD and dissociation became homicidal during his second EMDR session. Despite the numerous attempts by the therapist to calm him down, the latter withdrew within himself and started to become very agitated, behaving as if he was being tortured anew. The patient then became acutely homicidal toward the therapist and remained so for days.
The patient had to be restrained, physically and chemically, for days in the psychiatric ward. A homicidal tendency toward this clinician haunted this Veteran for months.17 This is not good for both patient and clinician, obviously. Because of the popularity of EMDR, I could easily find personal testimonies detailing adverse effects of EMDR on the internet. However, for the last few years, it is almost impossible to find any testimonials against EMDR on the internet. Here are examples found in November 2014 from a search on www.google.com with ‘EMDR side effects.’
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First Testimonial. ‘’So… Yesterday I went for my first EMDR therapy treatment. We made a list of my “Top Ten Traumas” before hand and she told me to put stars around the top two most traumatic events so we could focus more on these. Before
I even left to drive to the session, I had worked myself up into a full blown anxiety attack. I was pacing around the house, heart rate through the roof, breathing heavy, mind racing, quickly getting worse and worse. I don’t know why all of a sudden, I was so freaked out about this therapy because when we previously discussed it I had no problems or concerns doing it.
Anyways, I got there in my panicked frenzy and my therapist suggested that maybe we start off with something a little less severe to start since I was so frazzled. She didn’t want me to feel worse than I already felt, not to mention I had a migraine working its way into my brain.
The session seemed to run smoothly, and Icould feel my progress. The heartache and pain I was feeling in my chest when we first started the session subsided quickly and was completely gone once we finished. My head felt a little cloudy, but I didn’t feel like I wanted to curl up into a ball and cry myself to death anymore.
I went home and laid on the couch for afew hours to “just veg” as she suggested. I felt lightheaded yet my brain felt heavy and “sloshy” in my head. My eyes started to droop and I decided to go to bed (I haven’t slept in almost three weeks, so the fact that I felt tired was a GREAT relief) and I fell asleep. Not into a deep sleep, since I know I was awake many times throughout the night, but it was sleep none the less. This is when the nightmares started.
One after the other after the other. I had numerous TERRIFYING nightmares about the apocalypse, being possessed by a demon, earthquakes, trains on fire full of people screaming to get out, running away from terrible things etc.
I NEVER have nightmares, and if I do they do not scare me. I am a huge fan of horror films and nightmares have always excited me. These did NOT excite me. I woke up this morning trembling and dizzy and hysterical.
I turned on the light, ran upstairs crying and almost fell over. My head felt like it weighed more than I did. I felt terror coursing through my whole body. I felt afraid and scared. The nightmares were so REAL. I had to turn all the lights on in my house and open all the curtains because I was afraid of the dark. I was afraid to go back down into my room because it was dark down there. Even when I went into the kitchen throughout the day to get something from the fridge, the thought of even looking towards the top of the stairs sent me into a panic.
All day I have cried. I was in hysterics so badly that my boyfriend left work to come over and check on me. I have never felt so out of control in my whole life. I do not feel like myself. I don’t feel like I am even in my own body. So, the point of this post is to ask if anyone has done EMDR and has had adverse effects like this. Does it get better? Do you think it will get worse with other treatments? This wasn’t even my worst trauma, will it be worse with treating my more severe ones? I did a bunch of research online about the side effects and found a bunch of people stating that it did not help with multiple traumas. I do not want to live feeling like this, it is unbearable. My … is worsening and I cannot turn my lights off or my heart starts to race and I start to lose it. Oh, not to mention I seem to be getting brain “shocks” or nervous system “ticks” where my head kind of shakes back and forth and sometimes even jerks to the left. Loud noises give me anxiety and hurts my ears. I tried to unload the dish washer this afternoon and the sound of plates clanging together was too much for me to handle. Ugh, hopefully someone reads this, sorry it is so long, ladydawn.”19
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Second Testimonial. “Many people have asked about EMDR, so I thought I would share part of what is going on with me… and it’s due to that awful treatment. I’ve been triggered and triggered and triggered these past few weeks. I am out of it. and I know it. Anyways, I did around three? sessions of EMDR last summer. I have multiple traumas stemming from childhood to last year. I did not know when I did the treatment that it is not recommended for someone with numerous traumas. After the first three sessions, I snapped and had to be medicated (I still am medicated now.) The first week or so after that I kept getting these horrid “things.” My traumas (not all but way more than I could handle) would flash like a picture book through my mind. I would have my eyes open and the whole room was flashing as if a bulb was going off… then I would go off the deep end and get violently ill for about a week. Since then I have noticed every time I get triggered, I have this weird “thing” happen to me. It is not a flashback. It is like the EMDR is burned into my brain… and it won’t stop. It’s painful and gives me migraines and my body shuts down…not to mention the horrid anxiety this event causes. I have no idea if this will ever go away at the present, nor what is causing it. I have no one to ask because this area sucks. I worry that it has damaged me. I just thought that for those of you considering this treatment. I don’t want anyone else to be stuck where I am from crappy information and a therapist that is too pushy for something that is very dangerous.”20
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Third testimonial. “I had a first session last week and ever since then I just feel dead. I can’t feel anything. Nothing. I am a shell, harboring nothing. Trigger- Self harm. I cut myself last night to see if I could feel and I couldn’t. I felt nothing. I realize the risk in harming oneself when one cannot feel, so I have chosen to not do it for the time being. I can’t feel anything. I am so dead inside it makes me sick. Using the word “numb” is an understatement. I am dead. It’s like I don’t even exist anymore. I’ve always experienced this in some way, but since the session I have been very bad.”21
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Fourth Testimonial. “I was treated for many traumas and I began to feel jittery and nervous. Not soon after I begin having hallucinations and hearing things. Mind you I never had this problem before… just depression and anxiety. For 10 years.“ 22
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At least one lawsuit for personal injury has been filed against the EMDR Institute. The Orange County Court in California accepted the complaint.23
Cognitive Processing Therapy
(CPT) CPT proponents have not reported adverse effects from the use of this TFT. Actually, they simply do not consider this important issue in their controlled clinical trials.24 However, testimonials reveal a different story.
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First Testimonial. After finding on my website a document I wrote on the limitations of TFT for PTSD,25 the parents of a Veteran reached out to me. Their son, a young Veteran, became acutely suicidal after CPT and remained so for 2 years. Later on, the VA decided to have him undergo a second round of CPT, even though the Veteran informed the VA staff that CPT had been damaging to him and he did not want to undergo such therapy again. A few weeks after terminating CPT, the young Veteran killed himself (personal communication, 2018). These parents also shared with me testimonies from VA personnel.
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Second Testimonial. “A VA counselor told me that he had the first 3 sessions of their traumafocused PTSD therapy (CPT) one time and quit. He told them he would never go there again. From his experience, a person with serious military PTSD can only go into the black-hole of PTSD depression a few times without never being able to get out and committing suicide. He’s been in the black-hole and barely was able to get out and will not ever knowingly go in again!” (personal communication, 2018).
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Third Testimonial. “I had the opportunity to talk to a Disabled American Veterans (DAV) counselor. His is himself an injured Vietnam Veteran with PTSD. He has a list of veterans he has helped that have committed suicide. He said that he has repeatedly been in PTSD meetings with the CPT staff at the VA. He has told them that their analysis of PTSD certainly missed something because in talking to veterans it isn’t working.” (personal communication, 2018).
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Fourth Testimonial. “I talked to a chaplain who worked in Iraq. He is totally disabled with PTSD. He told me that CPT does more harm than good for the vast majority of the vets that take it.” (personal communication, 2018).
Conclusion
TFTs have been shown to be efficacious in reducing PTSD symptoms to the point of a loss of diagnosis, but such remission is only partial and these ‘success stories’ usually remain with serious symptoms.26 How often does partial remission occur? In clinical trials in which participants are highly selected, partial remission occurs in only 50% of civilians and 33% of military personnel.27 Therefore, 77% of Veterans remain with a full-blown PTSD diagnosis after having engaged in TFT with all the associated risks. 27
Adverse effects are always part of the game in clinical practice, but they are particularly present with TFT. To prevent adverse effects, clinicians need to know about possible adverse effects and anticipate them. This task is hard because TFT originators and researchers have regrettably refused, and still refuse, for the most part, to acknowledge the reality of adverse effects induced by TFT.
Real-life stories of human beings experiencing adverse effects from TFT need to be told, acknowledged, and prevented. In the second part of this article, I will present some adverse effects attributable to PE, EMDR, and CPT, as observed by me or reported to me by colleagues.
References
1. American Psychological Association. Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults. 2017. https://www.apa.org/about/offices/directorates/guidelines/ptsd.pdf
2. National Center for PTSD. Treatment Comparison Chart. Understand PTSD Treatments. 2020. https://www.ptsd.va.gov/apps/decisionaid/compare.aspx
3. Foa, E.B., Rothbaum, B.O., Riggs, D., and Murdock, T. Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive-behavioral procedures and counseling. Journal of Consulting and Clinical Psychology, 1991, 59: 715-723.
4. Pitman, R.K. et al. Psychiatric complications during flooding therapy for post-traumatic stress disorder. Journal of Clinical Psychiatry, 1991, 52, 17-20.
5. Wampold, B.E et al. In pursuit of truth: A critical examination of meta-analyses of cognitive-behavior therapy. Psychotherapy Research, 2017, 27(1): 14–32.
6. Macklin, M.L. et al. Five-year follow-up study of eye movement desensitization and reprocessing therapy for combat-related posttraumatic stress disorder. Comprehensive Psychiatry, 2000, 41(1): 24-27.
7. Becker, C.B., Zayfert, C. and Anderson, E. A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD. Behaviour Research and Therapy, 2004, 43, 277-292.
8. van Minnen, A., Hendriks, L., and Olff, M. When do trauma experts choose exposure therapy for PTSD patients? A controlled study of therapist and patient factors. Behaviour Research and Therapy, 2010, 48: 312-320.
9. Barlow, D.H. Negative Effects from Psychological Treatments: A Perspective. American Psychologist, 2010, 65(1): 13-20.
10. Foa, E.B., Zoellner, L.A., Feeny, N.C., Hembree, E.A., and Alvarez-Conrad, J. Does imaginal exposure exacerbate PTSD symptoms? Journal of Consulting and Clinical Psychology, 2002, 70(4):1022-1028.
11. Pitman, R.K. et al. Psychiatric complications during flooding therapy for post-traumatic stress disorder. Journal of Clinical Psychiatry, 1991, 52, 17-20.
12. Schnurr, P.P. et al. Randomized trial of trauma-focused group therapy for Posttraumatic stress disorder: Results from a Department of Veterans Affairs cooperative study. Archives of General Psychiatry, 2003, 60: 481-489.
13. Tarrier, N. et al. A randomized trial of cognitive therapy and imaginal exposure in the treatment of chronic posttraumatic stress disorder. Journal of Clinical and Consulting Psychology, 1999, 67: 13-18.
14. Morris, D.J. The Evil Hours: A Biography of Post-Traumatic Stress Disorder. 2015. New York: Houghton Mifflin Harcourt Publishing. https://www.nytimes.com/2015/02/22/books/review/the-evil-hoursby-david-j-morris.html
15. McSweeney, L.B., Sheila A. M. Rauch, S.M.A., Norman, S.B., and Hamblen, J.L. Prolonged Exposure for PTSD. National Center for PTSD. 2020. https://www.ptsd.va.gov/professional/treat/txessentials/prolonged_exposure_pro.asp
16. EMDR Institute.What are the adverse side effects? 2015. www.emdr.com/faqs.html
17. Brunet, A. Complications thérapeutiques suite au traitement EMDR chez un vétérantraumatisé. Journal International de Victimologie, 2002, 1(1).
18. Kaplan, R. and Manicavasagar, V. Adverse effect of EMDR: A case report. Australian and Zealand Journal of psychiatry, 1998, 32(5), 731-732.
19. Anonymous. EMDR Side Effects. January, 2013. www.healthboards.com/boards/post-traumatic-stress-disorder-ptsd/934679-emdr-sideeffects.html.
20. Anonymous. EMDR Lashback: When EMDR Goes Wrong. January, 2007. www.myptsd.com/c/threads/emdr-lashback-when-emdr-goes-wrong.1388/.
21. Anonymous. Does EMDR have side effects? November, 2014. http://forums.psychcentral.com/psychotherapy/207530-does-emdr-haveside-effects.html.
22. Anonymous. EMDR Ruined My Life….And I Worry About My Sanity. Any Suggestions? 2017. https://www.reddit.com/r/EMDR/comments/54e98m/emdr_ruined_my_lifeand_i_worry_about_my_sanity/
23. Unicourt. Lisa Riggs Vs. EMDR Institute, Inc. September, 2017. https://unicourt.com/case/ca-ora-lisa-riggs-vs-emdr-institute-inc-810926
24. Resick, P.A., Wachen, J.S., Dondanville, K.A., et al. Effect of Group vs Individual Cognitive Processing Therapy in Active-Duty Military Seeking Treatment for Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2017, 74(1):28–36. doi:10.1001/jamapsychiatry.2016.2729
ABOUT THE AUTHOR
Dr. Louise Gaston, 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 over 15 years. She knows all major models of psychotherapy (dynamic, humanistic, cognitive, and behavioral) and has beentrained 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 which 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. Afterwards, she was 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.
Combat Stress Magazine
Combat Stress magazine is written with our military Service Members, Veterans, first responders, and their families in mind. We want all of our members and guests to find contentment in their lives by learning about stress management and finding what works best for each of them. Stress is unavoidable and comes in many shapes and sizes. It can even be considered a part of who we are. Being in a state of peaceful happiness may seem like a lofty goal but harnessing your stress in a positive way makes it obtainable. Serving in the military or being a police officer, firefighter or paramedic brings unique challenges and some extraordinarily bad days. The American Institute of Stress is dedicated to helping you, our Heroes and their families, cope with and heal your mind and body from the stress associated with your careers and sacrifices.