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Howard, R., Berry, K., & Haddock, G. (2021). Therapeutic alliance in psychological therapy for posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology and Psychotherapy.

The therapeutic alliance is a key therapeutic factor with a lot of research support. The alliance is the collaborative agreement between patient and therapist on the goals and tasks of therapy, and their emotional bond. A meta-analysis of 295 studies reported that the alliance is moderately and reliably related to patient outcomes, and that this effect cuts across therapy modalities, orientations, and diagnoses. Some clinical writers expressed concern that the alliance is more difficult to develop with patients with posttraumatic stress disorder (PTSD) because of psychological consequences of PTSD like avoidance, mistrust, emotion regulation problems that pose a barrier to developing an alliance. Further, the disrupted interpersonal relationships that is part of the PTSD experience may also inhibit the development of an alliance with a therapist. However, one could also argue that a strong therapeutic alliance that is characterized by an emotional bond between client and therapist might be highly therapeutic for patients with PTSD. This meta-analysis by Howard and colleagues is the first to systematically review the research on the association between the therapeutic alliance and patient outcomes following PTSD treatment. The meta-analysis included 12 studies of adults receiving treatment for PTSD. The aggregated correlation effect size was r = -.339 (95% CI: -0.436, -0.234) with low levels of heterogeneity among the studies indicating that the findings are reliable. The average effect size was moderate in size, robust to effects of an outlier, and there was little evidence of publication bias. The authors also conducted a sub analysis that indirectly compared in-person therapy (k = 8; r = -.323) to remote therapy (k = 4; r = -.390) in which they found no significant differences (Q(1) = 0.41, p = .524) in the alliance-outcome association.

Practice Implications

The findings add support to the larger research literature in psychotherapy about the importance of the therapeutic alliance to patient outcomes. In particular, the findings suggest that clinicians should develop a good therapeutic alliance when treating patients with PTSD in order to promote better outcomes. That is, therapists and clients must come to a collaborative agreement on what the goals of the therapy are and how the therapy will be conducted. In addition, developing an interpersonal therapeutic bond will help the patient to weather the challenges that are associated some PTSD treatments. The findings also suggested that the effect of the alliance was as strong when therapy was in-person versus remote – but this finding is not as reliable given the indirect nature of the comparisons.

Merz, J., Schwarzer, G., & Gerger, H. (2019). Comparative efficacy and acceptability of pharmacological, psychotherapeutic, and combination treatments in adults with posttraumatic stress disorder: A network meta-analysis. JAMA Psychiatry, 76, 904-91.

Posttraumatic stress disorder (PTSD) is a highly debilitating disorder characterized by re-experiencing trauma, avoidance of situations related to the trauma, negative mood and cognitions, and hyperarousal. The lifetime prevalence of PTSD in the population is about 8%, and PTSD is associated with a great deal of medical problems, and social and economic burden. Difference between a variety of psychological treatment approaches for PTSD are small and not statistically significant. Some treatment guidelines tend to recommend both psychotherapy and pharmacotherapy to treat PTSD, but other guidelines indicate only psychotherapy as the first-line treatment. Merz and colleagues conducted a meta-analysis to examine comparative outcomes and acceptability of psychotherapy and pharmacotherapy and their combination in adults with PTSD. The authors focused on randomized controlled trials because these designs tend to produce the most reliable evidence. The authors identified 12 published studies with a total of 922 participants. Six of the studies included data on long term outcomes. The meta-analytic procedures that the authors used in this study included network meta-analyses (which some have argued may produce unreliable results) and direct comparison meta-analysis (which is more reliable, but resulted in fewer studies being included here). I report in this blog only results that were consistent between the network and direct comparison analyses. Pharmacological and psychotherapeutic treatments and their combinations were not significantly different in their effectiveness immediately post-treatment. However, at long-term follow-up psychotherapy was significantly more beneficial than pharmacotherapy (SMD, −0.63; 95% CI, −1.18 to −0.09). Combined psychotherapy plus pharmacotherapy was not significantly more effective that pharmacotherapy alone (SMD, −1.02; 95% CI, −2.77 to 0.72), and combined treatment was not more effective that psychotherapy alone (SMD, 0.06; 95% CI, −0.31 to 0.42). There were also no statistically significant differences between psychotherapy, pharmacotherapy, or their combination in the acceptability of treatments to participants as defined by differing rates of dropping out from the studies.

Practice Implications

This meta-analysis of a small number of studies suggests that psychotherapy produces better long-term outcomes than pharmacotherapy for PTSD. There is also a suggestion that combining psychotherapy and pharmacotherapy does not improve outcomes compared to either treatment alone. This research area seems to be new and not well developed, but so far, the results seem to favor psychotherapy for longer term outcomes. These findings are similar to those from a larger meta-analysis for depression. In that study, the authors suggested that the long-term benefit of psychotherapy was due to participants learning coping and interpersonal skills that were not gained from receiving pharmacological intervention alone.

Gutermann, J., Schwartzkopff, L., & Steil, R. (2017). Meta-analysis of the long-term treatment effects of psychological interventions in youth with PTSD symptoms. Clinical Child and Family Psychology Review, 20, 422-434.

Natural disasters, physical abuse, sexual abuse, war, accidents, loss and severe illness are traumatic events that can occur during childhood and adolescence. These potentially traumatic events are highly prevalent in youth, and approximately 15% of children and adolescents who have been exposed to traumatic events meet the diagnostic criteria for post-traumatic stress disorder (PTSD). Criteria for a diagnosis of PTSD include: intrusive memories of the traumatic event, avoidance, hyperarousal, and negative change in mood or cognitions. PTSD symptoms are also highly stable over time, and so without intervention they do not tend to improve. In this meta-analysis, Gutermann and colleagues assess the effects of psychological treatments for PTSD in youth, with a special emphasis on their long term therapeutic effects. Forty-seven studies of 3767 participants were included in the analyses. Traumas were varied and included childhood abuse, physical abuse, accidents, wars, and natural disasters. About 68% of interventions were CBT-oriented, and 67% were provided in a group therapy format. The uncontrolled pre-treatment to follow-up effect sizes for PTSD symptoms was large for studies with a follow-up period greater than 6 months (N = 30; g = .99, CI .83, 1.16). However, when psychological interventions were compared to treatment as usual or an active control group in a randomized controlled trial, the effects at post-treatment were small (N = 6; g = .38, CI .03–.74), and effects at follow up periods combined were also small (N = 19; g = .38, CI .20, .55).

Practice Implications

Psychological interventions resulted large effects to reduce PTSD symptoms from pre-treatment to follow-up from treatment. However, compared to treatment as usual or other active control groups, psychological treatments resulted in small effects in the longer term. There were too few studies to assess different treatment approaches, age groups, and modalities (group vs individual). Nevertheless, the results provide support for the efficacy of psychological treatments for PTSD in youth with modest effects at follow-up.

Author email: Gutermann@psych.uni-frankfurt.de

Morina, N., Malek, M., Nickerson, A., & Bryant, R.A. (2017). Meta-analysis of interventions for posttraumatic stress disorder and depression in adult survivors of mass violence in low- and middle-income countries. Depression and Anxiety, DOI: 10.1002/da.22618

There is a high prevalence of post-traumatic stress disorder (PTSD) in countries that have experienced civil war and mass violence, and given the number of open conflict, the prevalence is likely increasing. Most people affected are from low- to middle-income countries. Both PTSD and depression confer a large personal, social, health, and economic burden especially when untreated. Research in Western countries show that psychological treatment of PTSD is effective, but there are practical barriers to transporting and adapting these interventions to low- and middle-income countries. In this meta-analysis, Morina and colleagues do a systematic review of psychological interventions for PTSD conducted of adult survivors of war in low- and middle-income countries. Treatments included trauma-focused cognitive-behavioral therapy, interpersonal psychotherapy, eye movement desensitization and reprocessing and several others. In total, 2,124 treated participants and 934 participants in the waitlist condition were included in the analyses. In the 18 trials that were included, symptoms of PTSD and depression were measured. The average drop-out rate was 11.5%. Across all active interventions (k = 16), a large pre–post effect size was found, g = 1.29; 95% CI = [0.99; 1.59] for PTSD. The average between-group effect size comparing active treatments versus control conditions at post-treatment was small to medium, g = 0.39; 95% CI = [0.249; 0.55], and at follow-up was large, g = 0.93; 95% CI = [0.56; 1.31], k = 10. Pre-post effect size for depression was equally large g = 1.28; 95% CI = [0.96; 1.61]. The effect size comparing active treatments versus control conditions for depression at posttreatment (k = 11) was large, g = 0.86; 95% CI = [0.54; 1.18], and at follow-up was medium to large, g = 0.90; 95% CI = [0.49; 1.33], k = 5.

Practice Implications

Evidence-based psychological treatments developed in high-income countries are also effective in reducing symptoms of PTSD and depression in adults who experienced war-time conditions in low- and middle-income countries. Although not directly tested, the evidence suggests that different evidence-based treatments were equally effective. Even if drop-out rates were low, practical barriers still existed, including the number of sessions of these treatments (average was 10 sessions), the need for trained personnel, and the need for face to face meetings. The authors suggested that collaborative care models should be evaluated and tested which aim to enhance the reach of efficacious treatments within primary care to optimize the number of patients who can benefit from these interventions.

Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162, 214–227.

The psychotherapy research literature on treatment of post traumatic stress disorder (PTSD) has focused on cognitive behavioral therapy (CBT, with exposure and/or cognitive restructuring) and eye movement desensitization and reprocessing (EMDR). Exposure therapy involves confronting memories of the trauma or cues related to the traumatic event. Other CBT skills include developing skills for anxiety management or challenging distorted cognitions. In EMDR the patient is asked to develop an image of the traumatic event while tracking a bilateral stimulus. Most studies demonstrate the effectiveness of CBT for PTSD in the short term. However, many studies have excluded patients with comorbid conditions. For example, patients with PTSD often also have significant other symptoms like depression, substance abuse, other anxiety disorders, and personality disorders. In this meta analysis, Bradley and colleagues were interested in documenting the overall efficacy of psychological treatments for PTSD. They also wanted to report on any evidence on the long term efficacy of treatments for PTSD, and on evidence of the effects of excluding patients with comorbid disorders. Bradley and colleagues included randomized controlled trials published between 1980 and 2003 (i.e., 26 studies representing 1,535 patients). Also, they looked at outcomes defined in a few ways: change in symptoms as documented by the effect size, proportion of patients no longer meeting diagnostic criteria for PTSD (but who may have residual symptoms), and proportion whose symptoms improved significantly. Across all treatments, the average pre to post effect size was large (d = 1.43), and comparisons to control conditions were also large (d = .83). The results suggested that psychotherapy produced substantial effects for PTSD. Differences between types of therapy (CBT, CBT with exposure, EMDR) were negligible. Fifty six percent of patients no longer met criteria for PTSD, and 65% showed improved symptoms. At follow ups, 62% no longer met diagnostic criteria for PTSD and 32% were deemed improved, but the number of studies with follow up data were small (k = 10) and so the results could be unreliable. Of those who started treatment, 78.9% completed the therapy. Of those who were assessed, 30% were excluded because of suicide risk, drug or alcohol abuse, or “other serious comorbidity”.

Practice Implications

Treatment guidelines from the International Society for Traumatic Stress Studies list a number of effective treatments for PTSD. The evidence for efficacy is strongest at post treatment, and more research is necessary to demonstrate efficacy in the longer term. There is currently little evidence that any one treatment approach is more effective than another, and some researchers are debating whether specific interventions like exposure is necessary to treat PTSD. Bradley and colleagues argue that we need more research on alternative treatments for PTSD and research on patients with multiple symptoms and comorbidities.

Author email: rbradl2@emory.edu

Ehring, T., Welboren, R., Morina, N., Wicherts, J.M., Freitag, J., & Emmelkamp, P.M.G (2014). Meta-analysis of psychological treatments for posttraumatic stress disorder in adult survivors of childhood abuse. Clinical Psychology Review, 34, 645-657.

Post-traumatic stress disorder (PTSD) occurs at a very high frequency among those who experienced childhood physical and/or sexual abuse. As adults these individuals often request mental health services. Previous meta analyses of psychotherapies for PTSD have combined samples of those with PTSD due to childhood maltreatment and those due to trauma in adulthood. This meta analysis by Ehring and colleagues is the first specifically to look at treatment of PTSD in those with childhood abuse. Some argue that PTSD due to childhood abuse is different because of the high level of complex symptoms like emotion regulation problems, impulsivity, depression, dissociation, substance abuse, and others. And so treatments for PTSD related to childhood abuse may require different characteristics and may have different outcomes. Further, there is a long standing debate about whether trauma-focused treatments are appropriate for those with PTSD who have high levels of complex symptoms. There is concern for example that the focus on trauma memories may exacerbate symptoms like dissociation. Previous reviews showed that treatments targeting the trauma memory (i.e., focus on processing the memory and its meaning) had the largest effect on PTSD outcomes. This is likely because of the impact that memory processes (i.e., re-accessing memories, maladaptive attributions of memories) have on the maintenance of the disorder. Would these large treatment effects also be found in PTSD that resulted specifically from childhood abuse? (A note about meta analyses: meta analyses are the best way to synthesize a research area because this method combines the effect sizes from multiple studies into a single effect size. The findings of meta analyses are much more reliable than findings from any single study. See my November 2013 blog). Ehrling and colleagues conducted a meta analysis of 16 studies that included over 1200 participants with PTSD due to childhood abuse. Treatments included: trauma-focused cognitive behavioral therapy (CBT), non-trauma-focused CBT, eye movement desensitization and reprocessing (EMDR), and others. Psychological interventions were effective for PTSD related to childhood abuse, and the effects were large for both PTSD symptom severity and for other symptoms (i.e., depression, anxiety, dissociation). Psychological interventions were more effective that control conditions (i.e., wait lists or treatments as usual), and these effects were moderate. Effects remained large or moderate well into post-treatment follow-ups. Trauma focused treatments were more effective than non-trauma-focused treatments, and individual interventions were more effective than group-based interventions.

Practice Implications

Psychological interventions for PTSD in adults who experienced childhood abuse are effective in reducing symptom severity with moderate to large effects. Other symptoms like anxiety, depression, and dissociation also showed large positive changes in these individuals. Research shows that trauma-focused treatments are under-used in routine practice. This may be due to the concern that trauma-focused treatments may not be safe in some individuals with complex symptoms. Trauma-focused treatments may lead to higher effects than non-trauma focused treatments, indicating the potential importance of processing the trauma memory.