The guidelines are supposed to reflect the best scientific evidence. In fact, they ignore all scientific evidence except one kind of study, called a randomized controlled trial (RCT).
RCTs randomly assign people to treatment or control groups. They can answer certain questions (Is a medication more effective than a sugar pill?) and not others (How does the medication work? What causes the disease?). In the absence of careful scientific reasoning, RCTs can lead to foolish conclusions.
Here’s an example: Some people wrongly concluded that tooth flossing lacks scientific support after a review of RCTs found little evidence of benefits. But flossing is beneficial in the long run and the RCTs followed participants for only brief periods. They found exactly what you would expect—pretty much nothing. Knowledge about tooth flossing comes from other sources including dentists’ observations over more than a century, and an understanding of the mechanism of action—how it works.
The researchers conducted studies that were expedient to carry out, not studies that answered meaningful questions about flossing. They could not have conducted them if they wanted to. An RCT that could provide meaningful information would require some people to avoid flossing for years. Institutional review boards would reject that as unethical.
Most science does not rely on RCTs
The basic or hard sciences, like physics, chemistry, or astronomy, do not rely on RCTs. No astronomer ever conducted an RCT, but knowledge in astronomy progresses. Astronomers had no problem predicting the time and path of the recent solar eclipse over North America, down to the millisecond.
But some people, primarily in the social sciences, would have us believe that RCTs are the gold standard of scientific knowledge and all else can be ignored.
This is stupid and it doesn't require a science degree to understand why.
No RCT has ever shown that the sun causes sunburn, sex causes pregnancy, or food deprivation leads to starvation. We know these things because we can observe cause and effect relationships and because we understand the mechanisms of action. Ultraviolet radiation damages skin cells. Sex allows sperm cells to fertilize egg cells. People die without food. Flossing removes dental plaque, which harbors bacteria that attack teeth and gums.
Copernicus, Galileo, Darwin, Einstein, Niels Bohr, Marie Curie, Stephen Hawking. What do they have in common? None of them ever conducted an RCT.
Wrong questions, wrong answers
What does tooth flossing have to do with new guidelines for treating trauma? As it turns out, everything.
Psychotherapy takes time. Psychotherapy follows a “dose-response” curve. It takes more than 20 sessions, or about six months of weekly therapy, before 50 percent of patients show meaningful improvement. It takes more than 40 sessions for 75 percent of patients to show meaningful improvement.1 These findings, based on the scientific study of more than 10,000 therapy cases, dovetail with what therapists report about successful psychotherapy2 and what patients report about their own therapy experiences.3,4
The RCTs behind the trauma treatment guidelines considered only therapies of 16 sessions or fewer. Most of the therapies were eight sessions or fewer. In other words, the guidelines are based exclusively on studies of treatments known to be inadequate.
It was a foregone conclusion that the guidelines would recommend brief, standardized forms of CBT that are conducted by following instruction manuals. This kind of therapy is expedient to study with RCTs, therefore the only kind of therapy considered. Other research strategies would almost certainly lead to different conclusions (for example, studying patients who actually get well and what helped them).
More than a century of scientific research and clinical experience points to other therapy approaches as more helpful, especially longer-term therapies that build a relationship of trust between therapist and patient and focus on what is emotionally meaningful to individual patients (versus standardized interventions from instruction manuals). But since this knowledge does not come from RCTs, it was ignored.
The guidelines are by researchers for researchers. The needs of patients and therapists are secondary. The guidelines comprise 675 pages of densely complex minutia about research methodology and statistical analysis, including 537 pages of tables and forms. Therapies are designated “highly recommended” based on the research methods used to study them, not because patients get well.
Truth in advertising
“These guidelines offer the field a number of benefits,” says the APA. “For providers, they offer recommendations… that quickly summarize which treatments have been shown to work for hundreds or even thousands of patients… For families, they provide clear information on best treatments and what to expect of them.”5
Let’s fact-check this by seeing how it aligns with the findings of the largest and arguably best RCT behind the guidelines. The RCT was funded by the U.S. Department of Veterans Affairs and the Department of Defense and published in the Journal of the American Medical Association.6 It studied 255 female veterans. The most frequent trauma was sexual trauma followed by physical assault.
Patients received a “highly recommended” form of CBT (prolonged exposure therapy) or a placebo treatment.
Here is what the study found:
- Nearly 40 percent of patients who started CBT dropped out. They voted with their feet about its value.
- Sixty percent of the patients still had PTSD after completing treatment.
- One hundred percent of the patients were clinically depressed after completing treatment.
- At a six-month follow-up, patients who received CBT were no better than those in the control group.
- Nineteen serious “adverse events” (suicide attempts, psychiatric hospitalizations) occurred over the course of the study.
- The authors noted that patients “may need more treatment than the relatively small number of sessions typically provided in a clinical trial.”
I did not choose this study as an example because it is a poor study. I chose it because it is arguably the best. In fact, two-thirds of patients who receive APA's "highly recommended" treatments still have PTSD after treatment.7
“Clear information on best treatments and what to expect of them.” Really?
First, do no harm
Health insurance companies discriminate against psychotherapy. Congress has passed laws mandating mental health “parity” (equal coverage for medical and mental health conditions) but health insurers circumvent them. This has led to class action lawsuits against health insurance companies, but discrimination persists.
One way health insurers circumvent parity laws is by shunting patients to the briefest and cheapest therapies. Another way is by paying only for therapy that is so impersonal and dehumanizing that patients stop going. Health insurers do not say the treatment decisions are driven by financial self-interest. They say the treatments are scientifically proven—and point to treatment guidelines like those just issued by the APA.
It’s bad enough most Americans don’t have adequate mental health coverage without also being gaslighted and told that inadequate therapy is the "best" therapy.
The APA’s ethics code begins, “Psychologists strive to benefit those with whom they work and take care to do no harm.” APA has an honorable history of fighting for patients’ access to quality care.
Blinded by RCT ideology, the APA just handed a trump card to the worst apples in the health insurance industry.
© 2017 by Jonathan Shedler
1. Lambert, M.J., Hansen, N.B., Finch, A.E. (2001). Patient-Focused Research: Using Patient Outcome Data to Enhance Treatment Effects. Journal of Consulting and Clinical Psychology, 69, 1590-172.
2. Morrison, K.H., Bradley, R., Westen, D. (2003). The external validity of controlled clinical trials of psychotherapy for depression and anxiety: A naturalistic study. Psychology and Psychotherapy: Theory, Research and Practice, 76, 109-132.
3. Mental Health: Does Therapy Help (1995, November). Consumer Reports, 734-739.
4. Seligman, M.E.P. (1995). The Effectiveness of Psychotherapy: The Consumer Reports Study. American Psychologist, 50, 12, 965–974.
5. Deangelis, T. (2017, November). PTSD guideline ready for use. Monitor on Psychology, 48(10), 26-27.
6. Schnurr, P.P., Friedman, M.J., Engel, C.C., et al. (2007). Cognitive Behavioral Therapy for Posttraumatic Stress Disorder in Women: A Randomized Controlled Trial. Journal of the American Medical Association, 297, 820-830.
7. Steenkamp, M.M., Litz, B.T., Hoge, C.W., Martmar, C.R. (2015). Psychotherapy for military related PTSD: a review of randomized clinical trials. Journal of the American Medical Association, 314, 489-500