Abstract
Considerable research has been conducted on particular approaches to the psychotherapy of post-traumatic stress disorder (PTSD). However, the evidence indicates that modalities tested in randomised controlled trials (RCTs) are far from 100% applicable and effective and the RCT model itself is inadequate for evaluating treatments of conditions with complex presentations and frequently multiple comorbidities. Evidence at levels 2 and 3 cannot be ignored. Expert-led interventions consistent with the emerging understanding of affective neuroscience are needed and not the unthinking application of a dominant therapeutic paradigm with evidence for PTSD but not complex PTSD. The over-optimistic claims for the effectiveness of cognitive–behavioural therapy (CBT) and misrepresentation of other approaches do not best serve a group of patients greatly in need of help; excluding individuals with such disorders as untreatable or treatment-resistant when viable alternatives exist is not acceptable.
Highlights
Reviews and guidelines present the evidence base for post-traumatic stress disorder (PTSD), but rarely overtly identify the dichotomy between the patients seen in research studies and those with the range of clinical presentations encountered after traumatic experiences, even though the evidence indicates that modalities tested in randomised controlled trials (RCTs) are far from 100% applicable and effective.[4]
We have argued that the evidence for particular approaches to the psychotherapy of complex PTSD indicates that so-called ‘evidence-based’ modalities - defined as much by those clinical cases excluded as those included - are far from 100% applicable and effective.[4]
NICE3 recommended chronic disease management strategies if trials of evidence-based therapies (TF-cognitive-behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR)) were ineffective for PTSD; the guidelines did not differentiate the evidence base for PTSD from that for complex PTSD. These treatments are likely to have been found ineffective for complex PTSD
Summary
Recognition of the neurobiological insults imposed by complex trauma and the implications for psychotherapeutic interventions{. There is evidence that even those with non-complex posttraumatic disorders may be reluctant to seek treatment for their condition.[5] Rates of help-seeking for PTSD are lower than for similar mental disorders such as depression[5] and studies both internationally and in Northern Ireland have shown extended time to seeking treatment (12-22 years).[6,7] Reasons given in the USA by those not in treatment who recognised that they needed help included a perceived lack of effectiveness (it would not help or did not help in the past), dissatisfaction with services, stigma or fear of forced hospitalisation.[5] If the wrong treatment paradigm has been offered or the individuals have felt labelled as treatment-resistant or as having a personality disorder, they will be less likely to present again for help and will either not seek any treatment or seek it elsewhere. Rigorous level 2 (case controlled trials, non-randomised) or level 3 (observational studies including surveys) evidence is frequently accepted in medicine when it would be difficult to apply RCT methods, either because of unrealistic statistical power demands or because of a likelihood of harm to patients assigned to a cohort which did not receive the active treatment; for example, the acceptance of psychological first aid after disasters where denying core elements of the approach would be unethical
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
