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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.

Courtois, C. A. & Brown, L. S. (2019). Guideline orthodoxy and resulting limitations of the American Psychological Association’s Clinical Practice Guideline for the Treatment of PTSD in Adults. Psychotherapy, 56(3), 329-339.

Recently the American Psychological Association (APA) published clinical practice guidelines for the treatment of post-traumatic stress disorder (PTSD). The reaction from the clinical community that treats those with PTSD, client groups, and from many academic and research quarters was swift and negative. APA received almost 900 comments in their public consultations from many who felt the document was overly prescriptive, overly symptom-focused, and narrow in its recommendations. In this interesting inside look at the process, the Chair of the PTSD Practice Guidelines Committee (Christine Courtois) and a senior member of the Committee (Laura Brown) wrote a scathing commentary of the process imposed on them by APA that constrained the Committee’s access to information which affected their decisions. The Committee was bound by APA’s use of the Institute of Medicine (IOM) rules for developing practice guidelines. In other words, a psychological organization (APA) used a biomedical model to define what is relevant research, how to define treatment, what is an appropriate outcome, and how to decide on recommendations. As a result, the APA Committee reached several conclusions/decisions that were biased or premature. First, they defined PTSD only by its symptom presentation and not for the complex disorder that it is. In other words, PTSD was viewed almost exclusively from within a framework that defined it as only a fear-based response to a stressor. Such an approach downplays any developmental or attachment-related factors in the genesis or maintenance of PTSD. Second, the Committee was instructed to ignore a vast array of research on therapist factors, relationship factors, and client factors in psychotherapy. This runs counter to many clinicians’ views that one cannot engage in technical interventions related to PTSD symptoms without the patient experiencing a heightened sense of security in their relationship with the therapist. This also meant that the Committee largely ignored cultural and diversity factors. Third, the treatment recommendations focused on time-limited exposure-based interventions – which is a natural outcome of the first two decisions (i.e., seeing PTSD as only fear-based, ignoring issues of development, and ignoring relational factors in the treatment context). The authors were also disappointed that the APA ignored its own policy on evidence-based practice that puts equal weight on research, clinician expertise, and client factors when making clinical decisions. In the end the authors clearly were not confident in the narrow focus of the Clinical Practice Guideline, and they were concerned that clinicians, researchers, policy makers, and third party funders could misuse the Guideline to limit research, theory, and funding.

Practice Implications

In this extraordinary piece, the Chair and a senior committee member of the PTSD Practice Guideline Committee were highly critical of the process and outcome of APA’s effort to develop clinical practice guidelines for PTSD. The authors did not diminish the importance of exposure-based interventions for PTSD, however they did argue that these interventions must be offered only after clinicians take a sufficient amount of time to create a clinical context characterized by clients experiencing heightened safety in the therapeutic relationship, and to into account client preferences and culture. Further, clinicians should be highly sensitive to attachment-related insecurities and developmental traumas that may lengthen the treatment and that may have a complicating impact on the therapeutic relationship.

Norcross, J. C., & Wampold, B. E. (2019). Relationships and responsiveness in the psychological treatment of trauma: The tragedy of the APA Clinical Practice Guideline. Psychotherapy, 56(3), 391-399.

The American Psychological Association’s (APA) Clinical Practice Guideline for Posttraumatic Stress Disorder in Adults published in 2017 was met with a great deal of concern and criticism by the community of scholars and practitioners working with patients with PTSD. A key concern was that the APA used a biomedical model and not a psychological or contextual model in guiding their understanding of PTSD, their approach to what constitutes evidence, and to decisions about recommended treatments. In particular, the biomedical approach focuses almost exclusively on treatment methods, and down-plays the context of treatment (i.e., the relationship, patient factors, and therapist responsiveness). In this critique, Norcross and Wampold highlight the flaws in the APA Clinical Practice Guideline for PTSD, and the authors focus specifically on those variables that are known to predict patient outcomes but that were ignored by the Guideline. Norcross and Wampold highlighted that there exists numerous meta analyses that demonstrate that all bona fide psychotherapies work about equally well for trauma, and that the particular treatment method has little impact on PTSD outcomes. Yet, the restrictive review process undertaken by APA all but ignored this well-established finding. Also ignored was the research on the importance of the therapeutic relationship in the treatment of trauma. One review outlined nineteen studies that found that the therapeutic alliance was associated with or predicted reduction in PTSD symptoms. This is consistent with the general psychotherapy research literature, in which the alliance is the most researched and most reliable factor related to patient outcomes. Also missing from the PTSD Guideline was reference to a large body of research on therapist responsiveness to patient characteristics. Patients are more likely to improve if their therapists can adapt to the patient’s coping style, culture, preferences, level of resistance, and stage of change. In one study of cognitive-processing therapy (CPT; a treatment recommended by the APA Guideline), there were substantial differences between therapists in their patient’s PTSD symptom outcomes. That is, some therapists reliably were more effective than others, even though all therapists were trained in and supervised in providing the same manualized evidence-based treatment. Among the identified skills of the most effective CPT therapists were: a flexible interpersonal style, and an ability to develop and maintain a good therapeutic alliance across patients.

Practice Implications

There is growing consensus that the APA Clinical Practice Guideline for PTSD are based on dubious methodology and are of limited use to therapists and their patients with PTSD. Psychotherapists should practice a bona-fide therapy for PTSD, but should do so by taking into account the treatment context. In other words, more effective therapists are good at developing, maintaining, and repairing the therapeutic alliance across a range of patients. Effective therapists can also respond and adapt to patient characteristics such as level of resistance, coping style, culture, and stage of change. And so, even when providing a treatment based on the APA Guideline, therapists should nurture trust in the therapeutic relationship and be adaptive to their patients’ characteristics.

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.

Foa, E., McLean, C.P., Zang, Y., Rosenfield, D., Yadin, E… Peterson, A. (2018). Effect of prolonged exposure therapy delivered over 2 weeks vs 8 weeks vs present-centered therapy on PTSD symptom severity in military personnel: A randomized clinical trial. Journal of the American Medical Association, 319, 354-364.

Post-traumatic stress disorder (PTSD) can affect 10% to 20% of military personnel returning from combat. PTSD is often chronic and debilitating, and is associated with symptoms that are distressing, that lower quality of life, and that negatively impact family and loved ones. Prolonged exposure therapy (PE) has been tested in the past, and researchers have claimed that it is an efficacious treatment in civilians and veterans. PE is a form of behavior therapy and cognitive behavioral therapy characterized by re-experiencing the most traumatic event through remembering it and engaging with, rather than avoiding reminders of the trauma. In their treatment guidelines, the American Psychological Association (APA) proposed PE as a recommended treatment for PTSD. In this randomized controlled trial, Foa and colleagues assess if providing PE in intensive short time frame (massed exposure; 10 sessions over 2 weeks) was as effective as standard exposure (10 sessions over 8 weeks) for 370 military personnel in the US with PTSD. That is, the authors were interested to see if providing the same amount of therapy based on exposure in a shorter time was just as effective. They also compared the two versions of PE (massed and standard exposure) to two control conditions: present centred therapy (PCT) that is largely supportive therapy that does not rely on exposure to the trauma, and a no treatment control condition. The main outcomes were reductions in level of PTSD symptoms and reductions in PTSD diagnoses at post-treatment and up to 6 months post-treatment. Massed and standard PE were equally effective in reducing symptoms and diagnoses of PTSD compared to no treatment. However, PE was not more effective than PCT in reducing symptoms and diagnoses, and PCT was more effective than no treatment. Overall, reductions in PTSD symptoms and reduction in PTSD diagnoses were modest. Drop out rates were high at about 50% for all conditions.

Practice Implications

Drop out rates were high and outcomes were modest for these short-term psychological treatments for PTSD in military personnel, such that over 60% still had a diagnosis of PTSD at 6 months follow up. And PE therapy did no better than a control condition (PCT) that simply provided support with no exposure to the trauma. These findings are similar to other research in this area. Psychotherapy for trauma may require more time to work, and perhaps different models of understanding and treating the disorder. As Shedler recently remarked, it takes at least 20 sessions/weeks before 50% of clients improve. So it may not be surprising that 2 or 8 weeks of therapy had only a small impact on PTSD symptoms.

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