The guidelines are supposed to reflect the best scientific evidence. In fact, they ignore all scientific evidence except one kind of study, called randomized controlled trials (RCTs).
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 is the disease? What are its causes?). 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 patients for only brief periods. They found exactly what you would expect — pretty much nothing. Knowledge about flossing’s benefits comes from other sources, including dentists’ observations over more than a century and an understanding of the mechanism of action — how it works.
RCT researchers conducted studies that were expedient to carry out, not studies that answered meaningful questions about tooth 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, and astronomy, do not rely on RCTs. No astronomer in history 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 misguided, 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.
Most scientific knowledge does not come from RCTs.
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 clinically meaningful improvement. It takes more than 40 sessions before 75 percent of patients 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 treatments2 and what patients report about their own therapy experiences.3,4
The RCTs behind the trauma treatment guidelines studied only therapies of 16 sessions or less. Many were eight sessions or less. In other words, the guidelines considered only therapies that are inadequate.
It was a foregone conclusion that the guidelines would recommend only brief, standardized forms of CBT which are conducted by following step-by-step instruction manuals. They are the only therapies that are expedient to study with RCTs (in contrast, say, to studying patients who actually get better and what helped them).
More than a century of scientific research and clinical experience points to other therapy approaches as more helpful. But since this knowledge does not come from RCTs, the APA ignored all of it.
The guidelines are by researchers for researchers. The interests 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 as “highly recommended” because of 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. Most of the trauma was not combat-related. The most frequent trauma was sexual trauma, followed by physical assault.
Patients received one of the “highly recommended” forms of CBT (prolonged exposure therapy) or a control treatment.
Here is what the study found.
- Nearly 40 percent of those who started CBT dropped out of treatment. They voted with their feet about its usefulness.
- 60 percent of the patients still had PTSD when the study ended.
- All patients were clinically depressed at the start of treatment and remained clinically depressed after treatment.
- At six-month follow-up, patients who received CBT were no better than those who received the control treatment.
- Nineteen serious “adverse events” occurred over the course of the study, including suicide attempts and psychiatric hospitalizations.
- The authors soberly noted that the 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.
“Clear information on best treatments and what to expect of them.” Really?
First, do no harm
Many 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 continues.
One way that health insurers circumvent parity laws is by shunting patients to the briefest and cheapest therapies. Another way is by making therapy so impersonal and dehumanizing that patients drop out. Health insurers do not publicly say the treatment decisions are driven by economic self-interest. They say the treatments are scientifically proven.
It’s bad enough that 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 good care and against health insurance company abuses.
Blinded by RCT ideology, the APA inadvertently handed a trump card to the worst apples in the health insurance industry.
Jonathan Shedler, PhD is a Clinical Associate Professor at the University of Colorado School of Medicine. He lectures to professional audiences nationally and internationally and provides online clinical consultation and supervision to mental health professionals worldwide. Like his Facebook page to learn about new posts or discuss this one.
This article was originally published by Psychology Today.
- 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.
- 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.
- Mental Health: Does Therapy Help (1995, November). Consumer Reports, 734-739.
- Seligman, M.E.P. (1995). The Effectiveness of Psychotherapy: The Consumer Reports Study. American Psychologist, 50, 12, 965–974.
- Deangelis, T. (2017, November). PTSD guideline ready for use. Monitor on Psychology, 48(10), 26-27.
- 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.