Why “Evidence-based Practices” for PTSD are Not!

The American Psychological Association’s position statements regarding “evidenced-based practices” (EBPs) have caused major rifts within the mental health practitioner community. The problems began when APA adopted a 1990 policy stating that only treatment methods demonstrating superior reductions in symptoms based on a research method called randomized controlled trials (RCTs) should be considered “evidence-based.” Results from other research methods such as practical clinical trials or case studies were thereafter essentially disavowed as valid measures of effectiveness due to the APA’s EBP policy. Researchers are now producing evidence, however, that “evidenced-based” approaches for PTSD (e.g., cognitive behavioral therapies) are no more effective than other methods. And because the RCT has been touted as the “gold standard” in evaluating the effectiveness of trauma methods, the controversy in this area of research has intensified. In 2019, APA doubled down by disseminating a PTSD Clinical Practice Guideline in which Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), and Cognitive Behavioral Therapy (CBT) were “strongly recommended” for treating adults with PTSD.

At the same time, other researchers have cautioned against the exclusive use of RCTs to evaluate trauma method effectiveness. Tom Frieden (2017), the Director of Centers for Disease Control during the Barack Obama administration and many others contend that the overuse of RCT’s in determining treatment effectiveness could result in substandard patient care. Frieden also argues that RCTs are expensive, take years to complete, and their results may not be generalizable beyond the population studied. Further, Frieden asserts that RCTs may be a “good fit” for evaluating pharmaceuticals, but not for long-term psychological treatments like PTSD.

Several RCT studies, meta-analyses and reviews of PTSD treatment effectiveness research (Bisson et al., 2007; Schnurr et al., 2007; Benish et al., 2008;  Miller et al., 2013; Van der Kolk, 2014; and Steenkamp et al., 2015) have reported that treatment with cognitive behavioral therapies is only “marginally successful,” and produce no better results than non-trauma therapies. Among the shortcomings found in reviews of cognitive behavioral therapy effectiveness are: 1.) elevated dropout rates; 2.) statistically significant but negligible improvements in subject symptoms; 3.) symptom regression following treatment; and 4.) many subjects keep their PTSD diagnosis months after treatment.

Nevertheless, cognitive behavioral therapies are described by the APA as “treatments of choice,” the “best bet” and “most effective” methods for PTSD. Simply put, the evidence does not match the rhetoric. For a more extensive review of this topic I suggest you read chapters 2 & 3 in Multichannel Eye Movement Integration: The Brain Science Approach to Easy and Effective PTSD Treatment.


American Psychological Association. (2019). Clinical practice guideline for the treatment of
Posttraumatic stress disorder: Cognitive behavioral therapy (CBT).

Benish, S., Imel, Z. E., & Wampold, B. E. (2008). The relative efficacy of bona fide psychotherapies of post-traumatic stress disorder: A meta-analysis of direct comparisons. Clinical Psychology Review, 28, 746−758. https://www.sciencedirect.com/science/article/abs/pii/S0272735807001845?via%3Dihub

Bisson, J., Roberts, N., Ehlers, A., Matthews, R., Pilling, S., Richards, D., & Turner, S. (2007). Psychological therapies for chronic posttraumatic stress disorder: Systematic review and meta-analysis. British Journal of Psychiatry, 190: 97-104. https://doi.org/10.1192/bjp.bp.106.021402

Frieden, T. (2017). Why the “gold Standard” of medical research is no longer enough. STAT, August, 2017. https://www.statnews.com/2017/08/02/randomized-controlled-trials-medical-research/.

Miller, L. E., Hubble, M., Chow, D. & Seidel, J. (2013). The outcome of psychotherapy: Yesterday, today and tomorrow. Psychotherapy, 50(1), 88-97. https://doi.org/10.1037/a0031097

Schnurr, P. P., Friedman, M. J., Engel, C. C., Foa, E. B., Shea, M., Chow, B. C., . . . Bernardy, N. (2007). Cognitive behavior therapy in women: A randomized control trial. JAMA, 297 (8): 820-30. https://jamanetwork.com/journals/jama/fullarticle/205769

Steenkamp, M. M., Litz, B. T., Hoge, C. W., & Marmar, C. R. (2015). Psychotherapy for military-related PTSD: A review of randomized clinical trials. JAMA, 314 (5):489-500. doi:10.1001/jama 2015.8370.   https://jamanetwork.com/journals//jama/article-abstract/2422548

Van der Kolk, B. A. (2014). The body keeps the score: Brain, mind and body in the healing of trauma. New York: Penguin Books. https://www.barnedandboble.com/w/the-body-keeps-the-score-bessel-van-der-kolk-md/1117229987      

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