This article emphasizes the need to apply the long-standing ethical principles of the American Psychological Association (APA) to the treatment of Post-Traumatic Stress Disorder (PTSD), beyond any APA guidelines. This urgent need is illustrated by a real-life clinical example, exposing the real possibility of severe adverse side effects induced by any trauma-focused therapy (TFT). In this article, TFT refers to prolonged exposure (PE), Eye Movement Desensitization and Reprocessing (EMDR) and Cognitive Processing Therapy (CPT). TFTs entail re-experiencing a traumatic event as intensely as possible. TFTs are at best strenuous for all participants and damaging at worst, because PTSD at its core involves a strong impulse to avoid the distress triggered by thinking, talking, or visualizing the experienced traumatic event. Avoidance is a necessity for the person to not become overwhelmed, emotionally and physiologically, which could lead to destabilizing adverse effects. In treating PTSD, ethical principles should be applied.
Beneficence and Nonmaleficence
Let’s start by stating a shocking truth for many. The adhesion to research conclusions or clinical guidelines for treating PTSD can result, unfortunately, in a disregard of the Ethical Principle of Beneficence and Nonmaleficence of the American Psychological Association.1
Principle A: Beneficence and Nonmaleficence – ‘‘Psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons, and the welfare of animal subjects of research. When conflicts occur among psychologists’ obligations or concerns, they attempt to resolve these conflicts in a responsible fashion that avoids or minimizes harm. Because psychologists’ scientific and professional judgments and actions may affect the lives of others, they are alert to and guard against personal, financial, social, organizational, or political factors that might lead to misuse of their influence.’’1
2016 Amendment – 3.04 Avoiding Harm (a) – ‘‘Psychologists take reasonable steps to avoid harming their clients/patients, students, supervisees, research participants, organizational clients, and others with whom they work, and to minimize harm where it is foreseeable and unavoidable.’’1
A clinical example is hereby presented to illustrate the core argument of this article. By offering a TFT to a Veteran (Jack) presenting with severe PTSD, along with comorbid disorders, the professionals of Veterans Affairs (VA) simply applied the VA treatment guidelines for PTSD.2 They insisted on using TFT despite Jack’s repeated objections beforehand and Jack’s reports of severe adverse side effects between TFT sessions. Jack even implored them to offer him another therapy, but the VA professionals insisted that these reactions were just normal.
The VA guidelines for treating PTSD2 are very similar to the APA Clinical Practice Guidelines for the Treatment of Posttraumatic Stress Disorder (PTSD) in adults,6 which strongly recommend using TFTs for treating PTSD. The VA guidelines stated, ‘‘There are several effective treatments for PTSD. This quick guide can help you work with Veterans with PTSD to choose an effective option.’’2 On the VA website, the options offered for treating PTSD are TFTs only: PE, EMDR, and CPT. In addition, the VA guidelines dismiss the possible interference of co-occurring disorders. Unfortunately, the VA guidelines have been developed from biased research conclusions drawn by researchers who are highly enthusiastic toward TFTs, although some PTSD experts have repeatedly warned against TFTs due to their limited efficacy and adverse side effects.3,4,5
While the APA guidelines strongly recommend using TFT for treating PTSD, they oddly recognize later in their document that there are so many pitfalls in randomized clinical trials (RCT) that it is impossible to draw valid conclusions.6 The APA guideline committee even cautions against generalizing the available research findings to the general population due to obvious limitations found in RCT designs and a lack of data (p.86-87).6 Interesting, these last two assertions should have nullified their strongly emphasized recommendation of using TFTs for treating PTSD. From a philosophical standpoint, the principle of non-contradiction forces us to conclude that there is ‘no evidence’ in support for the use of TFTs for treating PTSD. The APA committee promoted a faulty recommendation, which has serious repercussions for PTSD sufferers. Unfortunately, blind adhesion to faulty conclusions seems to be operative nowadays.
PTSD Severity, Comorbid Disorders and Adverse Side Effects
In Jack’s case, the APA and VA guidelines ended up disregarding the complexity of his psychological condition and the risk of severe adverse effects from using CPT, a TFT. The VA professionals disregarded the first APA ethical principle of beneficence and nonmaleficence.1 Such disregard led to a tragedy for both Jack and his family.
In 2011, Jack experienced several traumatic events in Afghanistan. In 2017, Jack presented himself at the VA with a severe PTSD. Blindly, the VA professionals offered Jack only to participate in a TFT. The VA professionals should have never considered the use of a TFT as a treatment option for Jack for at least three reasons. Firstly, research conclusions from RCTs have only reported a partial efficacy of TFTs for treating PTSD in only 33% of the military volunteers.7Secondly, PTSD severity has been found to be the major predictor of the efficacy of TFT; the more severe the PTSD, the less efficacious is TFT.8Thirdly, severe adverse effects from a TFT have been reported for 33% of volunteers in a seminal study.5
Jack presented with multiple psychological disorders: severe PTSD, substance use disorder (alcohol), and major depression (with suicidal attempts). In addition, he reported having frequent outbursts of anger, associated at times with violent behavior. Clinically, these are all contraindications to using TFTs because such therapy is likely to induce adverse effects in such a highly destabilized individual. Nonetheless, policy was blindly applied in Jack’s case, and clinical common sense was disregarded by VA professionals, despite the caution issued by the APA guidelines suggesting that a substance use disorder is a contraindication for using TFT.6
Regrettably, such faulty decision-making is pervasive among clinicians. As much as 80% of PTSD sufferers present with comorbidities,9 while almost all RCTs on the efficacy of TFT for treating PTSD have entailed volunteers presenting with PTSD only. Scientifically speaking, findings on TFT efficacy should thus be generalized only to PTSD sufferers without comorbidity.
Foreseeable Adverse Side Effects
At onset, Jack repeatedly told the VA professionals that he did not want to talk about the traumatic events he had experienced in Afghanistan. Nevertheless, the VA professionals insisted on the merits of using a TFT, and Jack ended up conceding. After a few sessions, Jack mentioned that he was more angry and violent since the beginning of TFT and implored his therapist to stop therapy, but the latter blindly argued that exacerbations were normal and would subside, adding that Jack should persist because TFTs are both safe and effective.
Jack submitted to authority. In midst of treatment, he reported a resurgence of suicidal ideations, but TFT was continued upon the insistence of the therapist. Jack also reported getting drunk again and again. Although the aforementioned severe adverse effects should have been alarming, the therapist did not stop the TFT and did not address these adverse side effects. Following VA guidelines, the therapist insisted on completing the TFT protocol, and Jack submitted to authority understandably because he was trained as a soldier to follow orders.
In contrast, whenever a treatment provokes severe adverse effects, the treating professional is required, ethically speaking, to discontinue therapy or, at least, to adjust the therapeutic approach (see above, 2016 Amendment – 3.04 Avoiding Harm). Let’s consider a well-known medical analogy. Before prescribing penicillin, a physician will always verify if the patient has previously had an allergic reaction and, if so, the physician will prescribe another antibiotic. If the patient does not know, the physician will monitor the person’s reaction to penicillin and will immediately stop treatment if a severe reaction occurs. Why do mental health professionals not apply such ethical concern toward using TFT for treating PTSD?
Clinicians should always anticipate the possibility of severe adverse effects from any therapy, but especially TFTs. Instead, TFT practitioners seem to be only concerned about adhering to the TFT protocol. By doing so, TFT practitioners lose sight of patients even though humans are evidently more important than protocols. Clinicians need to realign their focus by considering clinical realities before protocols, their patients before guidelines.
As stated previously, conclusions from published research findings are at odds with clinical realities. As an example of faulty conclusions, let’s remember that Foa and colleagues, who are highly enthusiastic toward TFT, claimed that PE did not induce adverse side effects,10 while adverse side effects were easily found by Wampold and colleagues4 by re-examining the data of Foa and colleagues. Furthermore, clinicians believe that there are no serious adverse effects of TFTs because the vast majority of researchers simply have not examined this question,6 even if such endeavor is an essential part of any valid RCT according to Ioannidis.11 Instead of a blind adhesion to clinical guidelines, a realistic cautionary approach is ethical.
Before Jack’s participation in a TFT, cautionary knowledge about TFT was available.5 Consequently, no TFT should have ever been offered to Jack. No TFT should have been pushed upon him despite his objections and adverse reactions. Let’s take a look at these cautions.
It is very well known that trauma-related stimuli, such as those involved in re-experiencing a traumatic event during a TFT, can induce severe emotional and physiological reactions in individuals presenting with severe PTSD. In a pioneer study of the early 1980s,12 Vietnam Veterans with PTSD were found to sustain, for hours, highly elevated heart rate and endorphin secretion following the viewing of the ambush scene of the movie Platoon, while all other Veterans quickly returned to baseline. This sophisticated study illustrated how Veterans with severe PTSD can become highly destabilized, both psychologically and physiologically, upon being exposed to trauma-related stimuli. As TFTs involve re-experiencing a traumatic event, all TFTs should be expected to have destabilizing effects. Unsurprisingly, severe adverse effects were found in 33% of Veterans with severe PTSD having participated in PE.5
In a masterpiece article, Barlow emphasized the importance of both anticipating and identifying all adverse effects associated with any therapy.13 Barlow is a pioneer in the field of exposure therapy for anxiety disorders. Nonetheless, he emphasized the need to individually tailor any therapy to the specific needs of the person, and to consider the possibility of adverse side effects. Regrettably, Barlow’s appeal seems to have fallen onto deaf ears.
Now, does the partial efficacy of TFTs justify their risks? The answer is no. Indeed, the efficacy of TFTs is quite questionable. In civilians, only about 50% of volunteers lose their PTSD diagnosis, although they keep substantial PTSD symptoms.7,14With military personnel and Veterans, the loss of a PTSD diagnosis drops occurs in only 33% of volunteers, leaving 67% of Veterans still fully symptomatic.14 Beyond such limited efficacy, TFTs have also been shown to simply be as efficacious as non-TFTs.4,14,15 Thus, no claim of superiority can be made.
How about the effects of TFTs in the long run? It is now well demonstrated, although not known, that symptoms reductions associated with cognitive-behavioral therapies (TFT belongs to this category) have been shown to dissipate over time. Indeed, 40% of volunteers relapse within 6 months, 50% within 1 year, and 66% within 2 years.16 In sum, such therapies are only associated with temporary and partial efficacy. More worrisome, large PTSD deteriorations were found in the only study having examined the maintenance of TFT effects over several years. Despite moderate reductions of PTSD at the completion of EMDR, large deteriorations were equally found in both the EMDR group and the untreated control group at a 5-year follow-up.17 Taken together, these findings indicate high rates of relapse and deterioration over time, which clearly does not warrant the risk of using TFTs.
So, why do clinical guidelines recommend TFTs as the first-line treatment? Why does the VA insist on providing TFTs to Veterans with PTSD? This question is especially urgent given that it is well known that major factors interfere with the efficacy of TFTs such as the severity of PTSD, anger, and substance abuse. The PTSD severity at the onset of a TFT is a significant predictor of efficacy; more severe is the PTSD, the less beneficial is the TFT.8 Anger is also a predictor of the efficacy of PE; more anger, less benefits.10 Substance abuse as comorbidity is associated with adverse effects of TFTs; more substance abuse leads to more severe side effects.6 Given that Jack presented with a severe PTSD, had abused alcohol for years, had attempted suicide several times and had intense anger reactions following TFT sessions, the VA professionals should have anticipated serious adverse effects from using TFT with Jack, but they did not.
Tragic Disregard of Jack Himself
The APA guidelines notes that “the strength of the evidence on harms of psychotherapy was very low because data have not yet been rigorously collected and comprehensively reported.”6 This first portion of this statement is gravely misleading; ‘was very low’ should have been ‘cannot be determined.’ As a consequence, most professionals are now convinced that the risk of adverse effects from TFT is ‘very low,’ while these have simply not been examined in RCTs.18
The APA guidelines for treating PTSD,6 however, clearly call for caution regarding the presence of a disorder of substance use as a comorbidity of PTSD before using any TFT. This caution is based on a previous systematic review.19 Nonetheless, the VA personnel only offered Jack to participate in a TFT.
Before seeking help for his PTSD, Jack had presented with acute suicidality and excessive alcohol use. These ‘red flags’ were ignored by the VA professionals, along with the potential for adverse effects from using a TFT with Jack. The insistence on providing a TFT to Jack is particularly regrettable because Jack could have been offered a non-TFT for treating his PTSD. Indeed, there are many other types of psychotherapy for treating PTSD which do not entail re-experiencing traumatic events.20 It is thus highly questionable as to why the VA guidelines and professionals keep on insisting on providing TFTs to severely traumatized, unstable, and emotionally reactive Veterans. For Jack, such clinical decision disregarded the first APA ethical principle summarized as ‘Above all, do no harm.’ The VA professionals should have offered Jack psychotherapy tailored to his needs and capacities.
As demonstrated by Shedler,21 Jack could have been offered a long-term dynamic psychotherapy focused on the therapeutic relationship, which is flexible and has sustained benefits in the long-term. In contrast, TFTs are technique-focused (each session contains precise interventions to be employed) and short-term. In TFTs, the therapeutic alliance is overlooked, which is particularly contraindicated for suicidal patients such as Jack. According to the APA standard of care,22 clinicians need to pay particular attention to developing a therapeutic alliance whenever a patient presents with a suicidal tendency. With respect to PTSD, the recent APA guidelines indicate ‘‘…community members noted the importance of the development of a therapeutic relationship.’’6 To help Jack, the VA professionals should thus have considered his chronic and recurrent tendency towards suicidality and the reemergence of suicidal ideations during CPT. Was the use of a TFT worth their risks for Jack? Not at all.
After a few TFT sessions, Jack’s condition deteriorated. He reported having serious suicidal thoughts and had resumed his excessive consumption of alcohol. In addition, he developed an additional disorder; he now had regular panic attacks. Tragically, a few weeks after completing the CPT protocol, Jack killed himself.
From the standpoint of the ethical principle of ‘Benevolence and Nonmaleficence’ of the APA Standard of Care, the VA professionals should have anticipated that Jack’s suicidality would resume and even be heightened by a TFT. Mostly, they should have stopped using the TFT as soon as Jack reported anger outbursts, suicidal ideations, and a relapse in excessive alcohol consumption, because these are all signs of severe destabilization.
Unsurprisingly, the VA professionals declared that Jack’s suicide was due to a “personal condition.” Really! Cognitive dissonance is seriously at play here. Indeed, TFT practitioners are trained to focus on the TFT protocol and to disregard any alarming sign of destabilization. They are trained by TFT ‘experts’ that such reactions are temporary and normal. Therefore, TFT practitioners follow the party line and blindly believe and apply what they were told.
Unfortunately, such cognitive dissonance about TFTs has been pervasive for decades in the field of PTSD. Professionals can be so biased by clinical guidelines that they fail to consider any clinical reality screaming back at them. On one hand, I can empathize because these professionals are in a bind between VA guidelines versus APA ethical principle of beneficence and nonmaleficence. On the other hand, such disregard of a basic ethical principle is reproachable and should be corrected. Ultimately, the professionals issuing clinical guidelines for treating PTSD should go back and relearn true scientific principles.11
In 2017, Shedler loudly rejected the APA guidelines by writing, “The American Psychological Association (APA) just issued guidelines for treating PTSD. In my opinion, therapists and patients would be wise to ignore them. The guidelines are supposed to reflect the best scientific evidence, but they ignore all scientific evidence except one kind of study, called a randomized controlled trial. …In the absence of careful scientific reasoning, randomized clinical trials can lead to foolish conclusions.”3 I agree. How about you?
Note About the Author
Dr. Louise Gaston is a retired psychologist that was trained in both clinical practice and evaluative research. She was an assistant professor at the Department of Psychiatry at McGill University in Canada, but she resigned given the politics in research. Since 1991, Dr. Gaston has been the founder and director of TRAUMATYS, a clinic specialized in treating PTSD located in Quebec, Canada. She reports no conflict of interest given that she has experienced, practiced, and taught dynamic, humanistic, cognitive, and behavioral therapies, including some CBT trauma-focused techniques for PTSD.
American Psychological Association (2017). Ethical Principles of Psychologists and Code of Conduct. Including 2010 and 2016 Amendments. www.apa.org/ethics/code/
van Minnen, A. Arntz, A., & Keijsers, G.P.J. (2002). Prolonged exposure in patients with chronic PTSD: Predictors of treatment outcome and dropout. Behavior Research and Therapy, 40(4), 439-457.
Breslau N., Kessler, RC., Chilcoat, .H.D et al. (1998). Trauma and Posttraumatic stress disorder in the community: The 1996 Detroit area survey of trauma. Archives of General Psychiatry, 55, 626-632.
Foa, E.B., Riggs, D.S., Massie, E.D., & Yarczower, M. (1995). The impact of fear activation and anger on the efficacy of exposure treatment for posttraumatic stress disorder. Behavior Therapy, 26, 487-499.
Ioannidis, J.P.A. (2005). Why most published research findings are false. PLOS Medicine, 2(8), e124.
Blanchard EB, Kolb LC, Pallmeyer TP Gerardi RJ (1982). A psychophysiological study of post-traumatic stress disorder in Vietnam Veterans. Psychiatric Quarterly, 54(4), 220-229.
Barlow, D.H. (2010). Negative Effects from Psychological Treatments: A Perspective. American Psychologist, 65(1), 13-20.
Bradley, R., Greene, J., Russ, E., Dutra, L. & Westen, D. (2005). A multidimensional meta-analysis of psychotherapy for PTSD. See comment in PubMed Commons below American Journal of Psychiatry, 162(2), 214-27.
Ali, S., et al. (2017). How durable is the effect of low-intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study. Behaviour Research and Theory, 94 (1-8).
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.
Cusack, K. et al. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychological Review, 43,128-41. doi: 10.1016/j.cpr.2015.10.003. Epub 2015 Nov 2. PMID: 26574151.
Jonas, D.E., Cusack, K., Forneris, C.A., et al. (2013). Psychological and Pharmacological Treatments for Adults with Posttraumatic Stress Disorder (PTSD) [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Apr. Report No.: 13-EHC011-EF. PMID: 23658937.
Shedler, J. (2010). The efficacy of Psychodynamic psychotherapy. American Psychologist, 65 (2), 98-109.
Bongar, B. (2002). The suicidal Patient: Clinical and Legal Standards of Care. Second Edition. Washington DC: American Psychological Association.
ABOUT THE AUTHOR
Dr. Louise Gaston, a retired psychologist, founded in 1990 a clinic specializing in Post-Traumatic Stress Disorder, 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 been trained 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, MD, 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, MD, both ex-presidents of the International Society for PsychotherapyResearch 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.
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