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Vita

Andrew James Williams, Ph.D. 

Email-  DrAJWilliams@ProjectHealingHeroes.org

Educational History:

12/1986           Ph.D. in Counseling Psychology from the University of Texas at Austin

12/1980           B.A. in Psychology (with honors) from the University of Texas at Austin.                                                                                             

Licensure:

Texas State Board of Examiners of Psychologists, full Psychologist licensure (#23585) since June 13, 1988 (renewed through 12-31-2025)

 NPI#: 1962699009

 Employment History:

Currently retired as of 12/01/2019, but serve as Strategic Advisor to Project Healing Heroes (ProjectHealingHeroes.org) and Content Creator and Presenter for PTSD University

Carl R. Darnall Army Medical Center - Sleep Disorders Clinic Psychologist 09/2015-11/2018

* Performed initial evaluations on Active Duty Army service members who exhibited symptoms of post-traumatic sleep issues. Provided Cognitive Behavioral Treatment - Insomnia for appropriate candidates and provided alternative treatment of attachment, hyperarousal and nightmare issues. Provided biofeedback training for hyperarousal and Alpha Stim treatment for Chronic Pain. Attempted to establish a Neurofeedback component. Primary diagnoses treated were chronic Post-traumatic Stress Disorder, Chronic Pain, Anxiety Disorders, Depressive Disorders, Circadian Rhythm Disorders, Nightmare Disorder and Insomnia.

*Conducted Sleep Disorders Clinic Orientation classes and subsequent screenings as needed (usually weekly for the class, several times weekly for screenings).

* Created and conducted Insomnia Treatment Orientation classes

* Consulted with other staff on psychologically complex cases as needed.

* Received highest level employee ratings each eligible year

*Conducted treatment with soldiers from 89 different countries

Contractor, Disability and Assessment Review Service (SSDI). Self-employed. 01/2016-11/2017

*  Performed interview assessments on claimants for Social Security Disability (primarily PTSD, Major Depression and Autism Spectrum Disorders).

Olin E. Teague Veterans Administration Medical Center – Psychologist 11/2008-09/2015

Home-based Primary Care.  5/2010-9/2015

*Performed mental status screening, cognitive screening and psychotherapy for veterans unable to travel to a VA hospital or clinic for primary care. Approximately 60% of active caseload was PTSD and/or Military Sexual Trauma.  Approximately 75% also had nightmares, insomnia or circadian rhythm disorders. Developed and implemented Sleep Hygiene component. Also provided caregiver support counseling for spouses and significant others when needed. Participated in interdisciplinary treatment planning. Supervised two additional postdoctoral unlicensed psychologists. Continued to provide monthly case consultation with Killeen Heights Vet Center on complex cases. Performed Compensation and Evaluation examinations (primarily with PTSD).

PCT (Combat PTSD and related disorders) Clinic. 11/2008-4/2010.

*Performed intake screening, crisis intervention and suicide prevention, conducted individual, couples and group psychotherapies for veterans with combat trauma-related disorders. Ran two Nightmares groups and taught sleep hygiene as a component. Supervised one intern and two postdoctoral unlicensed psychologists. Performed Compensation and Evaluation examinations. Participated in interdisciplinary treatment planning.  Provided monthly case consultation with Killeen Heights Vet Center on complex trauma cases.

* Exceptional (highest level) Annual Performance Appraisals 2010, 2011, 2012, 2013, 2014

Fort Hood Resilience and Restoration Center – Psychologist  11/2007–11/2008.

* Performed screening, evaluation, diagnosis and treatment of soldiers, primarily for combat-related PTSD. Treated in crisis management, individual, couples and group formats. Performed Command-Directed Referral examinations. Performed Fitness for Duty, Line of Duty and Chapter Discharge evaluations. Attempted to establish a neurofeedback component. Worked with nightmares and persistent insomnia as part of an ongoing NCO PTSD group and in individual counseling. Consulted with spouses on PTSD issues.

Federal Prison Camp - Bryan - Trauma Treatment Program Coordinator  4/2001-11/2007

* Participated in a national Trauma Treatment Work Group in an effort to standardize trauma treatment protocols and training throughout the Bureau of Prisons.

* For my work with Trauma Treatment, I received the 2003 Bureau of Prisons Psychology Staff Member of the Year award out of approximately 300 psychologists and 350 other eligible treatment personnel.

* Co-authored the LIFT trauma recovery program proposal that led to the creation of this program and my position. The proposal covered such areas as staffing and budget, program rationale and philosophy, format and content of programming. Also wrote the ‘Trauma Treatment Program Coordinator’ Position Description adopted by the Bureau. Co-authored trauma history inventory and post-traumatic symptom inventory for use in this program. Have also created comprehensive Psychosocial History, Personal Autobiography, Dream Work, Memory Work and Symptom Logging and Management forms.

* Co-developed and continued to refine and coordinate a multi-stage, integrated trauma treatment program (LIFT) serving up to 172 inmates at a time in a female minimum security prison. Approximately 94.5% of our clients had co-morbid substance abuse diagnoses. It was for this program that I was named the 2003 Bureau of Prisons Psychology Staff Member of the Year. The recidivism rate for this program appears to have been the lowest of any program in correctional history (0.6% at 3 months and 3.0% at a 1-3 year post-release window for full program completers).

* Wrote theory and psychotherapy sections and co-wrote or edited sections on Relapse Prevention, Basic Therapy Skills, and Coping Skills modules for Trauma Treatment Program Manual used by both participants and providers. This included nightmares and insomnia treatment.

* Taught up to two Orientation to Trauma Work classes and facilitated up to twelve intensive trauma and attachment treatment groups weekly. These regularly involved treatment of depression, nightmares and insomnia. Frequently used hypnotherapy in both individual and group psychotherapy.

* Trained and supervised up to three doctoral psychologists and up to two doctoral-candidate practicum students at a time in trauma treatment theory and practice.

* Provided workshops and presentations on dream work, trauma and attachment issues to department staff of up to 8 psychologists and six bachelors’ and masters’-level drug treatment specialists.

* Arranged QEEG-driven Neurofeedback training program. Performed, processed and interpreted Quantitative EEGs, formulated treatment plans and provided neurofeedback training to clients with trauma and addiction issues.

* Oversaw budget and monitored spending for program

* Performed routine staff psychologist duties as specified below.

Federal Prison Camp - Bryan - Staff Psychologist 10/1995-4/2001

* Performed intake screenings (including trauma and abuse histories), crisis interventions and needs assessment evaluations, which resulted in diagnoses, problem definition and in recommendations to group, individual and monitoring treatment interventions for drug and alcohol abuse, major mental disorders, adjustment problems, sleep disorders, family issues, depression and anxiety disorders and the aftermath of trauma and abuse. Also made referrals to Medical department for psychiatric/ medication evaluation (also sat in with psychiatrist for two years). Frequently consulted with referring staff.

* During tenure as Program Manager for the Monitoring the Mentally ill Program, evaluated referred inmates for the presence of mental disability and included recommendations and referrals for treatment, treatment planning and monitoring, case management and referral to psychiatry or to a more appropriate institution. Also conducted monthly monitoring sessions for up to 90 mentally ill inmates, reviewed monitoring conducted by other staff and conducted periodic treatment compliance counseling sessions.

* During tenure as Program Manager for the Sexual Assault/Abuse Prevention and Intervention Program, conducted staff training, made presentations to incoming inmates and interviewed, evaluated and made treatment recommendations for inmates alleging such experiences. Also provided case management, monitoring and treatment services.

* Conducted both short-term and long-term individual psychotherapy with inmates presenting adjustment, personality disorder, dissociative disorder, depression, anxiety, attachment, grief and loss (primarily death of a child), substance abuse, trauma/abuse, sleep and family issues. Also performed crisis intervention counseling services. Treatment planning and case monitoring were routinely conducted.

* Conducted up to seven weekly Overcoming Multiple Trauma groups, including one cognitive-behavioral stabilization group. Also conducted one or two Introduction to Trauma Work classes weekly. In addition, saw several trauma and abuse survivors on an individual basis for both short-term and long-term psychotherapy. Created and periodically revised treatment plans for these clients, the vast majority of whom also had substance abuse histories.

* Supervised structured group and individual psychotherapy conducted by one to two doctoral-level graduate students (at any given time).

* Co-created and initially oversaw the operation of a graduated-intensity treatment program for all inmates requesting psychological services. Created and conducted an Orientation class, which resulted in problem definition and treatment recommendations in the form of an individualized treatment plan, which was then monitored and revised as needed. Also created and conducted individual classes for anxiety, depression and sleep management problems as well as up to three weekly psychotherapy groups.

* In 1995, reviewed ICC (Boot Camp) post-graduation failures and discovered that 83% had either a significant substance abuse history or had failed through a relapse on substances. In 2000, reviewed files on recent Boot Camp dropouts, Residential Drug Abuse Program post-graduation failures, incident report recipients (violators of institution and agency rules), inmates alleging sexual contact with staff and disciplinary transfers. Discovered that the vast majority of those for whom information was available had significant histories of trauma and abuse.

* In 2000, served as Program Review Team member. Have also participated in several in-house Operational Reviews, both for Psychology Services and for other departments.

* Have been through four Program Reviews, all of which resulted in “Superior” ratings, the highest rating available in the Bureau.

FPC Bryan - Drug Abuse Program Coordinator 7/1992-10/1995

* Conducted psychological screenings (including trauma and abuse histories), interpreted psychological assessment data (primarily MCMI-II and Shipley), diagnosed, generated treatment recommendations and monitored treatment progress and problems for residential drug program participants. Also conducted intake screenings for the general population.

* Conducted individual and group psychotherapy with substance abuse program and general population inmates, primarily for trauma and abuse issues. Utilized Gestalt, cognitive-behavioral, psychodynamic, guided imagery, experiential and reality therapy techniques.

* Coordinated and supervised the individual, group and classroom treatment planning and provision done by up to five Drug Treatment Specialists and up to five practicum students and volunteers. Provided specialized training in treating trauma and abuse issues to supervisees as well.    

* In the area of program development, co-created and implemented interim curriculum (estimated 250+ hours of programming) for female substance abusing inmates prior to the Bureau of Prisons completing its Residential Drug Abuse Program (RDAP) curriculum. Also arranged a week-long training program in a variety of relevant issues for RDAP staff members, psychologists and correctional counselors.

Cottonwood de Austin (Substance Abuse and Trauma Recovery) - Psychologist and Clinical Director 4/1990-2/1992

* Performed mental status examinations, gathered psychosocial histories (including substance abuse and trauma/abuse histories), interpreted intermediate psychological assessment batteries (MMPI, Myers-Briggs, Shipley and projective drawings) and provided feedback to all incoming patients and their assigned therapists. Also, conducted more comprehensive assessment batteries on “problem clients,” including the Rorschach Inkblot test, an assortment of neuropsychological subtests and intellectual assessment.

* As Clinical Director, supervised the treatment planning and provision of treatment interventions for Trauma Program clients, Dissociative Disorders Program clients and those Substance Abuse clients reporting trauma and abuse histories (the majority by far). Coordinated and supervised up to five master’s level and chemical dependency counselors.

* Conducted individual psychotherapy with problem clients, primarily those with dissociative disorders or particularly intense post-traumatic symptoms. Also led weekly therapeutic workshops for both substance abuse and trauma/abuse clients and conducted group therapy for trauma survivors.

* Directed and provided ongoing program development with Trauma and Dissociative Disorders programs and assisted with ongoing program development with Substance Abuse program. Prepared for and passed a JCAHO audit. Assisted in upgrade from Residential Treatment Center status to Hospital status.

Private Practice in Bastrop and San Marcos, Texas 10/1989-1/1993

* Conducted mental status examinations and psychosocial histories, including extensive substance abuse and trauma/abuse histories, made diagnoses, established problem definitions and collaborated on treatment plans on all clients during intake phase. Provided individual, group, family and relationship psychotherapy, primarily, but not exclusively, with trauma and abuse survivors. Worked routinely with nightmares and sleep disorders. Also, provided group psychotherapy to female teenaged trauma survivors through the Pebble Project in Austin.

* As co-creator (along with local Women’s Center) and clinical director of the Sexual Abuse Family Treatment project, conducted mental status examinations, projective drawing assessments, performed psychosocial histories, recommended and oversaw group-based treatment (supervised case staffings and 5 therapists) for childhood and adolescent trauma survivors and non-offending caretakers. Co-facilitated weekly group for Non-offending Caretakers of abused children and provided additional individual and family therapy services when needed.

* Conducted assessments on alleged perpetrators of sexual crimes against children, children and adolescents alleging sexual and/or physical victimization, and non-offending parents for Child Protective Services and the Bastrop County District Attorney’s Office. Diagnosis, problem definition and recommendations for treatment or other interventions were routinely part of the assessment process. Court testimony was provided when requested.

* Acted as consultant to the local Ministerial Alliance and made public presentations on matters relating to trauma and abuse.

* Supervised one unlicensed Ph.D. psychologist.

Riverwood Professional Center - Staff Psychologist 10/1987-10/1989

* Routinely performed intake assessments (including substance abuse and trauma/abuse histories) and made referrals for group, individual, chemical dependency, family and relationship interventions. Conducted individual, group, family and relationship psychotherapy with wide range of presenting problems and issues. Specialty services not itemized below included crisis intervention, group psychotherapy for abused children and for adolescent sex crimes perpetrators, individual psychotherapy with perpetrators of sex crimes against children and with the children they victimized, crisis debriefing, sleep disorders and nightmares, general family therapy and individual and family psychotherapy for Attention Deficit-hyperactivity Disorder.

* Provided assessment and consultation to clients in the Substance Abuse program.

* Assessed children alleging abuse, their perpetrators and caretakers for Child Protective Services, forensic referrals from Adult and Juvenile Probation, referrals from local physicians, and adolescent sex offenders from a local treatment center. Typical batteries included mental status examination and psychosocial history, plus intellectual, academic, projective and objective personality assessments. These assessments resulted in diagnoses (when appropriate), problem definition and treatment or referral recommendations. Collateral contact with parents, counselors and teachers was also routinely done with children. Also created and utilized a collaborative family drawing technique to assess functioning and alliances within families. Compiled and utilized intermediate-level neuropsychological screening battery for local adolescent mental hospital. Provided MMPI and mental status testing as a part of Law Enforcement Officer certification. Also conducted MMPI and mental status assessment on candidates for intensive outpatient drug abuse program.

* Served as consultant 1988-89 to Caldwell County Special Education Co-operative, conducting assessments upon children and adolescents referred for “emotionally disturbed” evaluation, placement and services. Typical battery included mental status examination and conducting a psychosocial history, along with administration and/or interpretation of both projective and objective assessment instruments. Also consulted on the handling of emergent sexual abuse cases.

* Provided psychotherapy, assessment and consultation services to intermediate care facility for mentally retarded. Diagnosis, problem definition, treatment recommendations and placement recommendations were given. Collateral contacts with teachers and institution personnel were included. Conducted individual psychotherapy with three multiple trauma survivors. Provided crisis management services to both residents and staff following the accidental death of a resident during a restraint maneuver by staff.

* Helped prepare for and pass two JCAHO accreditation audits

* Represented Riverwood in a work group of community agencies and service providers which created a protocol for interagency cooperation in child abuse cases.

* Supervised a postdoctoral unlicensed psychologist, master’s level therapists and practicum students from the local university (now Texas State University).

Central Counties Center for Mental Health and Mental Retardation - Coordinator, Milam County Office 9/1986-10/1987

* Conducted mental status examinations and psychosocial histories (including trauma and abuse histories) on all clients during intake phase and during routine monitoring for the purpose of diagnosis, problem definition, treatment recommendation and provision. Provided crisis intervention, monitoring and family consultation services to the mentally disabled and provided individual, family and relationship psychotherapy and counseling to the local community. Conducted individual and relationship therapy with survivors of trauma and abuse.

* Assessed sanity and competency, both as formal assessment batteries (Rorschach, MMPI, drawings, WAIS-R, etc.) and informally as mental status and psychosocial history examinations for criminal, civil and involuntary hospital commitment purposes. Assessment and testimony in county or district courts was provided on approximately 45 occasions.

* Assessed Law Enforcement Officers for the purpose of certification.

* Coordinated county office consisting of self, a case manager and two clerical support staff.

Anthony Arden, Ph.D., Psychologist in Private Practice - Assistant 12/1986-10/1987, Rockdale, Texas.

* Provided psychological assessment, problem definition, diagnosis and treatment referrals/recommendations and individual and relationship psychotherapy to referrals from Child Protective Services, the local schools and a local ALCOA factory’s Employee Assistance Program. Most of the cases referred included a history of trauma or abuse.

Internship and Practicum Experiences

* As predoctoral intern at Olin E. Teague Veteran’s Center in Temple, TX, participated in weekly Rorschach seminar, 8-week neuropsychology workshop which included interpretation of assessment batteries, and individual mentoring on the MMPI from MMPI researcher (estimated 20 hours). Also did medical unit assessments on approximately fifty patients and intake screenings on approximately one hundred veterans. Did full battery assessments (intellectual, mental status, psychosocial history, projective and objective personality measures) on approximately twenty veterans. Was taught interview techniques for dementia assessment and used them with approximately twenty veterans.

*   As predoctoral intern at Olin E. Teague Veteran’s Center in Temple, TX, performed evaluations and made admission and/or group, individual, placement, chemical dependency, assessment and psychiatric (medication) treatment recommendations and referrals. Settings and rotations included detox and follow-up substance abuse program wards,  intake and admissions, chronic care wards, surgical wards, inpatient psychiatric wards, and domiciliary. Provided crisis intervention, short-term and long-term group and individual psychotherapy to veterans, primarily with Post-traumatic Stress Disorder and Substance Abuse diagnoses resulting from combat in Vietnam, Korea and World War II. Did external rotation working with elementary and middle school children two days a week. Began learning techniques for treating insomnia and nightmares in combat veterans.

* Predoctoral practicum settings included a university counseling center, adult and adolescent inpatient wards at a State Hospital, the local school system and a local agency providing pro bono counseling and psychotherapy services to the community. Duties included intake interviews, suicide risk evaluations, full battery assessments, individual and group psychotherapy, crisis intervention and neuropsychological assessments.

Clinical Supervision

Received two-plus years of postdoctoral clinical supervision by a licensed psychologist at my request (in order to be licensable in those states requiring two rather than the traditional one year of postdoctoral supervision).

Have supervised approximately 27 unlicensed doctoral psychologists, master’s level therapists and practicum students, providing training in assessment, diagnosis and treatment planning and provision in substance abuse, attachment, trauma and general psychology.

Seminars, Workshops and other Advanced Training Attended:

Bureau of Prisons - Sexual Harassment (1 hour)

VA - Sexual Harassment (1 hour x 3)

VA- Suicide Prevention (3 hours)

VA - Brief Motivational Interviewing (2.5 hours)

VA - Cultural Diversity (4 hours)

AATBS Cultural Diversity (3 hours)

VA – Compensation and Pension Examinations (6 hours)

Army HIPAA training (8 hours)

VA HIPAA training  (9 hours)

2- Bureau of Prisons - Drug Treatment Training (64 hours)

Bureau of Prisons - Drug Program Coordinator Training (24 hours)

2 - Bureau of Prisons - Working with Female Offenders (40 hours)

Bureau of Prisons - New Psychologists Training (24 hours)

Summer Institute on Alcohol and Drug Abuse (40 hours)

Brazos Valley Council on Alcoholism and Substance Abuse - Sexual Trauma (8 hours)

Relapse Prevention (4 hours)

Pathological Gambling (4 hours)

Eating Disorders (4 hours)

2 - Menninger Clinic and Washburn University Brainwave Biofeedback for Trauma and Addictions (48 hours total)

Quantitative EEG and Neurofeedback (Dr. Bright) - Theory and Application (80 hours total)

Clinical Neuroanatomy (6 hours)

Psychophysiology for Neurofeedback (45 hours)

Neurofeedback Certification course (36 hours)

VA - Cognition and Memory after TBI  (1 hour)

VA National Center for PTSD/BOP - Treatment of Post-Traumatic Stress (32 hours)

VA – Treatment of PTSD (3 hours)

Bureau of Prisons - Family and Employee Assistance Team (post-traumatic debriefing - 20 hours)

Bureau of Prisons - Sexual Assault/Abuse prevention and Intervention (2 hours)

Critical Incident Debriefing (7 hours)

Critical Incident Debriefing/Crisis Support Team (24 hours)

International Society for Traumatic Stress Studies (24 hours)

Albuquerque -  Advances in Trauma Treatment (30 hours)

Master’s and Johnson - Advances in Sexual Trauma Treatment (16 hours)

Individual Supervision on Trauma Treatment (100+ hours)

Southwest Group Psychotherapy Association Workshops on Trauma and Group Psychotherapy - (20+ hours)

Group Psychotherapy with Sexually Abused Children - Pebble Project/SAF-T Project (16 hours)

2 - Baylor and V.A. Sexual Abuse Workshops (8 hours)

Boston – Advances in Trauma Treatment (18 hours)

Dallas – (VA) Cognitive Processing Therapy (19 hours)

VA - Military Sexual Trauma (7 hours)

Trauma and Addictions (12 hours)

Children Exposed to Domestic Violence (4 hours)

6 - American Society of Clinical Hypnosis (ASCH) - on Trauma and Hypnotherapy (120+ hours)

Hypnosis and Trauma (non-ASCH) (17 hours)

Individual Supervision in Hypnosis - Nicholas Dobrovolsky, Ph.D. (150+ hours)

Pain Management (2 hours)

Texas A&M - Personality Disorders (4 hours)

Hare PCL-R - Assessing Psychopathy and Antisocial Personality (4 hours)

Gangs (4 hours)

Mediation (4 hours)

Society for the Exploration of Psychotherapy Integration (14.5 hours)

University of Minnesota – graduate course in Attachment Theory (32 hours)

Advances in Attachment - A. Schore (3 hours)

Attachment Theory – A. Schore - advanced  (10 hours)

Repairing Attachment Trauma – PESI (14 hours)

Attachment and Emotional Regulation - PESI (5.5 hours)

Attachment in Adults - PESI (3.75 hours)

Neuroscience behind Development/Attachment Trauma - PESI (5 hours)

Attachment Styles and Therapy Outcomes  (5 hours)

Forensic Assessment (6 hours)

Harville Hendrix  (3 hours)

Center for Clinical Excellence (18 hours)

Rational Behavior Therapy (3 hours)

Cognitive Behavior Therapy (4 hours)

Dialectic Behavior Therapy (12 hours)

Ethics (51 hours)

Ethics for Rural Practice (3 hours)

Ethics and Boundaries (8 hours)

Ethics and Telemental Health (3 hours)

ADEC – Death, Dying and Bereavement (18 hours)

Caretaker Support – (2 hours)

Diagnosis and Management of Dementia (8 hours)

Dementia (8 hours)

Summer Institute in Aging 2011, 2012 (22.5 hours)

VA- End of Life Training (6.5 hours)

Integrated Mental Health in Home-based Care (1.5 hours)

DSM-5 (6 hours)

Therapeutic Communities (1 hour)

Religion, Spirituality and Psychotherapy (7 hours)

Introduction to Supervision (40 hours)

Supervision for Mental Health Professionals (6 hours)

Managing Multiple Projects (7 hours)

Burnout and Wellness (3 hours)

Program Review (40 hours)

Time Management (8 hours)

Supervisor-Supervisee Relations (8)

Sleep: an overview (1 hour)

Insomnia (3 hours)

Sleep and Aging (3 hours)

Sleep Disorders, Part 1: Children and Adolescents (4 hours)

Sleep Disorders, Part 2: Adults (4 hours)

Sleep Disorders, Part 3: The Elderly (4 hours)

SLEEP 2015 Conference and Workshops (32 hours)

SLEEP 2016 Conference and Workshops (19 hours)

Cultural Diversity 2015 (3 hours)

Cultural Diversity 2016 (3 hours)

Cultural Diversity 2017 (3 hours)

Cultural Diversity 2018 (3 hours)

Cultural Diversity 2019 (3 hours)

Cultural Diversity 2020 (3 hours)

Cultural Diversity 2021 (3 hours)

Intimate Partner Violence in Culturally Diverse Groups (3 hours)

Psychology of Immigration (4 hours)

Human Sexuality Across the Lifespan (3 hours)

Human Trafficking  (4 hours)

Workshops Created and Presented:

3 - Dreamwork and Trauma

3 - Sexual Abuse

Sexual Abuse and Developmental Disabilities

Personality Disorders and Substance Abuse

Female Offenders – Bureau of Prisons Annual Refresher Training (created and conducted)          

2 - Sexual Assault - Annual Refresher Training (created and conducted both times)          

Cultural Diversity - Annual Refresher Training (created and conducted)

2 - Assessment and Treatment of ADHD

2 - Suicide Prevention for Hotline Volunteers

Traumatic Ego State Theory

2 - Attachment and Trauma

Hypnosis, Attachment and Ego States (@ Society for the Exploration of Psychotherapy Integration)

Hypnosis

Trauma Treatment in a Correctional Setting

Projective Hypnotherapy (Day-long advanced-level workshop @ Annual Convention of American Society of Clinical Hypnosis)

Attachment and Psychotherapy

Seminar on Neurotherapy in Forensic and Correctional Settings (co-presenter at Annual Convention       of Association for Applied Psychophysiology and Biofeedback)

Attachment, Trauma, Hypofrontality, Hyperarousal and Sleep – Army Sleep Clinic (twice)

~44 hours total

Total CE attended or given = 1674.75

Awards:

Bureau of Prisons Sustained Superior Performance Award - 1996, 1997, 1999

Employee of the Quarter - 10-12/1999

“Superior” Program Review (highest rating)- 1996, 1999, 2002, 2005

Quality Step Increase/Outstanding Employee Evaluation - 2002, 2003

Federal Bureau of Prisons Psychologist of the Year, 2003

Exceptional Performance Appraisal, VA 2010, 2011, 2012, 2013, 2014

Exceptional Performance Appraisal, Army 2016, 2017, 2018

Relevant  Offices:

President-Elect of Brazos Valley Psychological Association in 1997, President in 1998, and Past-     President in 1999.

Strategic Advisory Board, Project Healing Heroes

TPA 2024 Presentation

“The Evidence Base for PTSD Treatment: Myths and Realities”

“The greatest enemy of knowledge is not ignorance; it is the illusion of knowledge.” Daniel Boorstin, historian

What I will be presenting is far more relevant to the EB for PTSD TX than to the EB for PTSD phenomena. Also, I had planned on and scripted for 3 hours, but received 1.5 hours. So, for the sake of providing adequate information within the time allotted, I will forego providing a comprehensive list of citations for each point I make. A more complete script, along with relevant citations, the bibliography and my vita, however, are available at ProjectHealingHeroes.org- the web address is on the hardcopy handout.

Disclosure:  I serve as a Strategic Advisor to Project Healing Heroes. I have also written and videotaped a 20+-hour series of PTSD-related presentations called PTSD University which will soon be housed on the PHH website. We will be submitting for PD approval shortly. But, I have not received and do not anticipate directly receiving any monies from either.

Every year, I review dozens to hundreds of research articles and abstracts searching for useful nuggets of information within the Evidence Base (EB) for PTSD theory, phenomena and treatment. Yet, I am first and foremost a clinician who places considerable value and faith upon clinical experience.

When working with PTA (Post Traumatically Adapted) clients, we confront symptom intensities, paradoxical reactions and behaviors, multiple co-morbidities and resistances to our interventions. Adding in the intensely unpleasant aversive elements inherent in every truly traumatic event and memory, the natural avoidance of such distressing experiences andthe commonly elevated interpersonal mistrust that a hx of trauma engenders, it becomes clear that therapeutic work with PT (Post-Traumatic) sufferers can be unpredictable and challenging. We are encouraged to rely upon the ST, manualized EB for guidance in treating PTSD. The APA and NIMH (National Institute of Mental Health) even stipulate the use of manuals in clinical work (Truijens, et al., 2018).

The EB for PTSD TX (Treatment) is promoted as containing research-verified realities, but I would assert that a rigorously critical review would reveal the vast bulk of the EB to be deeply flawed, as promoting more myths than facts. In this presentation, we will be examining the myths and facts in the EB for PTSD Tx.

MYTHS ABOUT TRAUMA reflected in the EB Research 

Myth: The only legitimate consequence of sufficiently intense or repetitive trauma is PTSD as defined in the latest version of the DSM

Reality: Heterogeneity not only exists in peoples’ responses to trauma, it is the norm, largely due to individual differences in attachment security, brain integrity, prior trauma histories and pre-existing and co-occurring conditions. (Carnevali, et.al., 2018, Seidermann, et.al., 2021)

Reality: Co-morbidity is the norm in PTSD. In the VVRS done in the late 1980s, 98.8% of VietNam veterans with PTSD had at least one additional MH dx (Kulka, et al., 1990); a subsequent study found the modal number of additional dxs to be 3+ (Kessler, et al., 1995); Subsequent studies have shown significant co-morbidity with non-combat PTSD as well (e.g., Spinazzola, et.al., 2021, Richardson, et al., 2017, Haagen, et al., 2017)

Co-morbid MH dxs include Depressive Disorders, PDs such as Antisocial and Borderline, Eating Disorders, Substance Abuse Disorders, Psychogenic Pain, several Anxiety Disorders and Adjustment Disorders, Dissociative Disorders, Sleep Disorders, milder Cognitive Disorders, etc.

List of PxH dxs includes hypertension, cancer, chronic pain, heart disease, sleep apnea, asthma, allergies, ulcers, headaches, epilepsy, mTBI, etc. Except for epilepsy and mTBI, all of the foregoing also show a dose-response relationship with traumatic experiences. (e.g., Eilers, et al., 2023, Chang, et al., 2019)

Destructive behaviors linked to trauma include smoking, recreational substance use, interpersonal violence victimization and perpetration, impulsivity, thrill-seeking, distortions of perception, social withdrawal and intolerance of emotional connection and intimacy.

plus many adverse consequences which are not recognized as formal dxs, including reduced Oxytocin receptor density and integrity (e.g., Nawijn, et al., 2019) and mirror neuron system impairment (e.g., Penagos-Corzo, et al., 2022, Tan, et al., 2019, Campbell, et al., 2018) consequent to the prolonged stress chemistry of hyperarousal. These compromise observational learning, interpersonal competence, connection and intimacy, attachment security, calming capacity (both internal and interpersonal), compassion, etc. Insecure attachment and trauma are highly associated (e.g., Bryant, R, 2023, Crow, et al., 2021, Gander et al., 2018, Spinnazola, et al., 2018) and insecure attachment is sadly quite common, but is not recognized in the DSM.

Some co-morbidities, such as alcohol abuse, chronic pain and TBI, also involve and adversely affect many of the same brain structures and neuronal change processes as does psychological trauma (e.g., Klaming, et al., 2018, Yang and Chang, 2019) (Price and Inyang, 2015)

Reality: per DHA, PTSD is #1 dx among active duty soldiers. Alcohol Abuse/Dependence is #2 (yes, I believe in the self-medication hypothesis), Back Pain is #3 and Sleep Apnea is #8. The rest are depressive, anxiety and adjustment disorders to complete the top 10.

Reality:  PT reactions can be excitatory/sympathetic dominant (glutamate, norepinephrine) OR inhibitory/parasympathetic dominant (acetylcholine + GABA), or have a mixed sympathetic-parasympathetic response pattern (see e.g., Liddell, et al., 2016, Sherin and Nemeroff, 2011). Again, heterogeneity.

Reality:  The modal LIFT diagnostic picture:  Depressive Disorder NOS (Dysthymic Disorder punctuated by periods of Major Depression), Substance Abuse/Dependence (94.5%), Nightmares, (plus, unofficially, Insecure Attachment, most often of the more severe disorganized/unresolved/fearful varieties)

Myth:  PTSD is some kind of abnormal reaction pattern

Reality:  Traumas are Unconditioned Stimuli and PT symptoms are often Unconditioned Responses- normal, natural, reality- and experience-based reactions serving survival and safety. E.g.,  increased paranoia and hypervigilance, along with shallow sleep- where one can still hear and easily awaken- serve survival in dangerous places. PT sxs are primarily driven by Unconditioned, living memories of internalized, subjective trauma. PTAs are most often deemed dysfunctional when the affected individual is not presently in a traumatic environment and their PT adaptations- although consistent with their internal reality- appear incongruent with present environmental realities.

Reality: The brain records traumatic experiences primarily in subcortical amygdala (e.g., Roozendaal and Nemeroff, 2009), along with the cortical visual and sensorimotor regions- and thus in a fast-responding, primitive and unreflective mode. Internalized Trauma then begets adaptations  (e.g., Beattie, et al., 2023, Pitman, et al., 2012), such as hyperarousal and insomnia which are, like all changes to existing homeostatic balances, initially-resisted- often vigorously. It’s how we get the unfeeling, tough dude John Wayne Syndrome among early career soldiers, EMTs and police. The underlying, initially-resisted brain adaptations, however, are likely to become the new homeostasis- the new equilibrium- if PTSD develops. Once set, change to these PT adaptations will themselves be resisted.

Myth:  One has to consciously remember a trauma to be affected by it

Reality:  PTAs are driven by (often unconscious) memory (e.g., Beattie, et.al., 2023), night and day.

Reality:  If conscious memory were required, then how do we account for Traumatic or trauma-symbolic dreams and nightmares, which may occur even when one has not thought about the relevant traumatic experience(s) all day or been consciously triggered by the day’s events. Where do traumatic dreams come from if not traumatic memories?

Reality:  Attachment styles are experientially-based and generally established and detectable around the age of 2-2.5, which is well prior to continuously or consciously retrievable memory for most people. If adverse attachment experiences (i.e., attachment trauma) wasn’t at least unconsciously remembered and wasn’t powerfully influential despite being unconscious, then how can insecure attachment behaviors and styles even come into temporary existence, much less tend to be lifelong? (e.g., Bowlby, 1969)

Myth:  PTSD symptoms and post-traumatic attitudes and perceptual distortions are voluntary, conscious choices

Reality:  Moment-by-moment Perception operates primarily at a rapid, automatic, unconscious, often subcortical level. Just because we can later describe a sensory or emotional inner reality in words upon demand by no means says that cortically generated words and conscious thoughts themselves are the driver, the main force behind what is expressed verbally. (“If I’m reacting this way, there must be a good, rational reason. Just give me a moment to make one up.”)

Reality:  Four of the most common residual sxs following EBTx for PTSD are re-experiencing, hyperarousal, nightmares and insomnia, which are fundamentally involuntary and rarely welcome in conscious awareness. (Citations in Residuals section) I would assert that if these residuals were conscious, voluntary choices subject to rational control and informed consent, we’d have far fewer sufferers.

The neurobiological adaptations which follow traumatic experiences occur automatically, and are neither simple choices nor require one’s conscious awareness or approval, much less informed consent. (e.g., Kuhn, et al., 2021)

Also, I would assert that conscious choice and conscious mentation are actually quite limited during sleep.

Myth:  What applies to impersonal, one-time car accident or natural disaster trauma survivors (e.g., Blanchard, et al., 2003) applies equally to the multiply traumatized, polytraumatized (different forms of trauma), and to combat and interpersonal trauma survivors

Reality:  Interpersonal and combat trauma tends to have more intense and enduring effects compared to impersonal trauma such as natural disasters and accidents. (Kachadourian, et al., 2023)

Reality:  The power of any memory or clustered schema of memories is largely a product of the intensity of the original experience(s) and the resulting memory images, plus the intensity of similar, associated prior or subsequent interconnected traumatic experiences. Pencil marks on a blank page.

Clinically, stronger memories appear to drive stronger, more energized, more rigid, more generalized and more treatment-resistant adaptations. This is reflected in the Adverse Childhood Experiences literature (e.g., Chang, et al., 2019, Schalinski, et al., 2016), which indicates that different types, combinations and quantities of adverse experiences produce more versus less adverse life outcomes.

Reality:  It is the accumulation of traumatic experience(s) reaching an invisible,  unpredictable and utterly individual threshold which is responsible for the disconfirmation, breakdown and surrender of one’s previous non-traumatic homeostatic balance and the movement toward PT adaptations. (e.g., Drozdek, et.al., 2020) When the pencil mark breaks through and disrupts the integrity of the paper and destroys the former picture of life.

Reality:  The trauma-exposed with PTSD and the Trauma-exposed without PTSD do show some significant overlap on fMRI and psychological testing, but also show distinct differences (e.g., O’Doherty, et al., 2018, Rauch, et.al., 2020, Liberzon, et al., 2003). Potentially very different groups of people, although the traumatized without PTSD may simply be at an intermediate stage of PTAdaptation. This is a crucial distinction to make when sampling to test PTSD txs.

MYTHS ABOUT EVIDENCE-BASED RCT RESEARCH

Myth:  Group data validly reflects individual realities

Reality:  Group means may distort individual realities. Especially true when variability (heterogeneity) within a sample is high OR when the sample exhibits a bimodal distribution of scores. Similarly, Group mean treatment improvements may well obscure significant variations in individual results (see, e.g., Cox, et al., 2023).

Reality:  When a particular diagnostic group is being studied and a particular minimum threshold of test scores is being used for subjects’ diagnosis and subsequent inclusion in a sample, the actual overall variability within the true populational range on a trait, symptom, response or characteristic is obscured and thus sample results may only apply to those in- or very similar to- the sample

Myth:  The Randomized Control(led) Trial (RCT) -dominated EB for PTSD tx reflects a committed search for the best treatment possible.

First, The Randomized Controlled Trial for PTSD TX paradigm is adapted from the medication RCT paradigm. In the RCT model, the focus is on a specific treatment technique or a specific active medication ingredient and a specific dx or symptom.

The RCT paradigm strives to minimize bias due to nonspecific factors (e.g., desire for improvement, subject characteristics and expectancies for success or failure, therapeutic relationship effects) in part through the randomization of the initial subject pool to active vs control conditions. An RCT also then requires effective control conditions, such as placebo pills identical in appearance and taste to the active pills. An RCT demands effective double-blinding, such that neither subjects nor treatment providers actually know who is in the active treatment group vs the control group- who is getting the inert sugar pill and who is getting the real medication. The RCT paradigm is also most compatible with a single dx and single, invariant active tx to minimize confounds.

(Frank, 1961) gave a list of needed controls for nonspecific factors: equal therapeutic relationship and equal therapist contact for all subjects, a rationale providing credibility for both active and control treatments), all procedures or rituals provided in a structured manner (such as a manual), and be delivered in a healing context or setting.

Reality:  RCTs are very expensive, often in the millions, plural. Who has that kind of money? Who doesn’t? Who funds the bulk of the RCT EB for PTSD tx? The NIMH, VA, DoD. How much do they pay out to PTSD researchers and research-based trainers? (In 2018, $136MM- Davis, et al., 2022). How does one obtain some of this money? By being a good fit for the funding sources’ agenda. What is the agenda of these funding sources? IMO, after working for government agencies for 28 years and reviewing many thousands of government-funded research articles, the agenda is driven by the funding agency’s Numbers Game, the “do less for more” paradigm. The end result is that government research monies go virtually exclusively to researchers promising a manual for the delivery of Cheap, short term, research-justified, mass production-compatible treatment techniques which only require minimally educated and marginally competent, but inexpensive providers who can follow a manual. The Army in 2007-2008 vs 2015. The Temple VA after Phoenix billions$$.  

Reality:  Researchers do not look for what they (or their funding source) do not want to find. It’s not a good career move. Giving the boss (or funding source) what they want is a great career move.

Reality: How many year-long, expertise-intensive PTSD treatment studies financed by the VA or Department of Defense (DoD) are you aware of?

Myth:  What works in the individual format works just as well in a group, so techniques validated with individual treatment subjects work just as well when used in cheaper group therapy, if of course you follow the manual.

Reality:  Resick, et.al., (2017).  In studying the Effect of group vs individual Cognitive Processing Therapy in active-duty military seeking treatment for posttraumatic stress disorder. Not even considering the bias potentially introduced by poor blinding (Bhattacharya et al., 2023, Enck and Zipfel (2019), individual CPT resulted in greater improvement than did Group CPT to the tune of a Cohen’s d= 0.6, a medium effect size and therefore potentially a very significant bias factor.

This would also apply if an active treatment were done in the individual format and a control condition conducted in a group format. I would imagine this IT advantage would be even greater when experimenters use a minimal treatment, no-treatment or waitlist control condition with little or no therapist contact.

I will be referencing the Foa, et al., 2018 SS Prolonged Exposure study as an example of RCT PTSD research. This study was funded primarily by the DoD, conducted through the STRONGSTAR research consortium, was published in no less than JAMA and listed 17 contributing authors- a prime example of CBT-PTSD research. They used the individual format for all active and control conditions, although one control condition was very brief and not conducted in person.

Myth:  There is no significant history of EBT/CBT Criticism, just lone, paranoid, wild-eyed malcontents whining in the wilderness.

Reality: There have been decades of valid criticism. E.G., Schnurr, 2003, Bradley, 2005, Steenkamp, et al., 2015, Leichsenring, et.al., 2022 

Myth:  The PTSD PTX EB is largely free of Bias Effects

Reality:  Dawson, et al., 2021 Review of 17 Exposure-based writing therapy studies found that 84.6% evidenced high or unclear bias

Worse, Leichsenring, et al., 2022 reviewed 112 meta-analyses on PTSD treatment studies done since 2014, representing 3782 RCTs and 650,514 subjects. They performed a formal bias risk assessment on each meta-analysis and they excluded high bias studies and those studies which used weak comparators (except for TAU-which I would have excluded due to excessive variation among different TAUs). Allowing the TAU CG studies, they nevertheless found only 9/112 qualifying studies (8%) could be validly considered adequately low bias.

That number of 9 valid PTSD meta-analyses compared to 127 valid meta-analytic psychotherapy studies on MDD and 522 valid pharmacotherapy meta-analyses. BTW, for PTSD pharmacotherapy they found a placebo-corrected effect size of .21.

They also noted that risk of bias was often high at the level of individual studies. Specifically, they reported that 90% of their reviewed treatment studies overall had high bias effects and only 10% had low bias effects. 

Even worse, Bhattacharya, et al., 2023 disallowing TAU as an automatically valid CG, found only 7 CBT RCT PTSD studies over the previous 5 years which were both adequately placebo controlled and low bias. 7 truly valid studies out of many hundreds.

The real point here is that the vast bulk of the EB for PTSD ptx must be considered invalid due to excessive bias and poor controls exaggerating the results of the active treatment under study.

SECTION:  SO, What types of bias can be found in the PTSD treatment EB?

Subject-related

Chronicity: clients with short duration of their disorder score better at post-test (e.g., Enck and Zipfel, 2019)

Tx Hx - No prior tx hx leads to higher placebo response (Enck and Zipfel, 2019) Yet, having prior treatment can be a serious blinding problem.

Treatment expectancy (often driven by desire for change, fear of consequences for not changing). Enck and Zipfel (2019)

Prior Trauma History and Insecure Attachment - very frequently cited precursors for PTSD development following a given trauma and negative factors for resilience and treatment response. (e.g., Schuman, et al., 2023, Castro-Vale, et al. , 2020, Sharma, et al., 2020, Overstreet, et al., 2021)

Self-report measures- the myth is that they are accurate enough, esp when verbal self-report is scored by an experimenter. (Hodgins, et.al., 2018)  Patient-report-based outcome measures are more susceptible to placebo reporting than are objective biomarkers, (e.g., Enck and Zipfel (2019), Carnevali, et al., 2018) which are very rarely used.  

Negative effects of high face validity (vs tx motivation)

Do test scores obtained in a calm, safe office environment reported by a person hoping for and expecting high quality treatment faithfully reflect their real-world functioning? In honor of this issue, early neuroimaging PTSD studies were often done with a Trauma Script-measured vs an at rest, no-trigger measurement- showed impressive differences (e.g., Hughes and Shin, 2011, Liberzon, et al., 2003)

When Low PTSD scorers dominate the sample

Low pre-test scorers are less likely to vs drop-out, more susceptible to placebo responding (Enck and Zipfel, 2019), more likely to have positive outcomes (e.g., Currier, et al., 2014), more easily lose the diagnosis, represent lower co-morbidity/complexity and thus be population-unrepresentative with respect to chronic PTSD (e.g., Knutsen,  et.al. 2020, Litz, et. al., 2019, Kline, et al., 2020, )

Higher placebo effects for low scorers/less affected/less chronic and when smaller control groups are compare to larger active treatment groups.  (Enck and Zipfel, 2019)

Foa, et al., 2018 (STRONGSTAR)

Fort Hood, now Fort Cavazos, was an infantry and mechanized armor post, at times with up to 53K soldiers posted there. Many soldiers there had already been through multiple year-long (or longer) combat deployments and PTSD was #1 dx of all types. So, no issue finding full-blown PTSD subjects, right?

YET, somehow… Mean pretest score was 25.2/51 vs a threshold of 23/51 for declaring “probable PTSD”

With a Standard Deviation of 6.36, 38% of Foa 2018 STRONGSTAR PTSD SAMPLE was BELOW this threshold

One reason:  Soldiers must be combat zone deployable. If not, due to any sufficiently severe MH or PxH condition, soldier may be involuntarily discharged via what is known as the Med Board process. So, the most severe cases of PTSD might already be in the Med Board discharge process or have been discharged already. Also, STRONGSTAR had an at least informal time-remaining-on-post requirements for inclusion. I am not accusing them of malfeasance due to real logistical issues regarding treatment completion and tracking discharges and transferees for follow-up but more severe cases would likely end up excluded from participation and that might account for the very low mean scores.

How did the researchers handle Outliers; i.e., extreme scorers? Removing outliers reduces the SD, which in turn makes it easier to reach the .5SD MCID threshold used to declare treatment response (re MCID, see Stefanovics, et al., 2018).

How was Dropout Data handled? (e.g., Berke, et al., 2019) Would introduce bias in outcomes if only completers were analyzed and dropouts ignored.

Dropout in CBT for PTSD is Inconsistent overall per some, (Alpert, et al., 2020), but rather high (50%+) per others (Lamkin, et.al., 2019, Gilmore, et.al., 2020)

Dropout is Elevated for PTSD subjects vs other anxiety disordered subjects (Carpenter, et.al., 2018) and Elevated for Trauma Focused-CBT and Imaginal Exposure vs Non TF control groups (e.g., Ford, et al., 2018, Fortney, et al., 2023, Thompson-Hollands, et al., 2023).

In all fairness, high dropout rates are unsurprising given that PTSD requires avoidance of traumatic cues and images for diagnosis.

One solution: Intent to treat samples as compensation  (Carpenter, et.al., 2018)

One problem with this strategy is we may not know how many dropouts leave in a state of emotional distress or actually experience relief and a lessening of sxs upon quitting (negative reinforcement).

Motivational and Commitment Issues (esp in Trauma Focused) (Bernardsdottir, et.al., 2023) (why do people come to a treatment study and how does that affect their reporting of symptoms? career, relationship, disability (compensation seeking), legal (criminal, custody), etc.)

Another potential source of bias is: Paid or unpaid subjects – VA rumor

AGE  Foa, 2018 SS:  the average age of their subjects (32.7) placed them near or just past the middle of their careers. Military members need to be at or very close to completing their 20-year minimum term of service in order to collect a retirement paycheck. If they are discharged from the service too early (voluntarily or involuntarily) due to their PTSD being too severe to permit safe combat zone deployment, they completely lose their monthly retirement paycheck at the same time that the severity of their emotional and/or medical conditions may make equivalent civilian jobs very hard to find and even harder to hold onto. Perhaps such just-past-mid-career subjects might just be motivated to inflate their CBT treatment improvement results if they believed that reporting treatment success meant losing the dreaded PTSD diagnosis, keeping their careers and thus avoiding imminent financial disaster for themselves and their families? 

Subject and Provider Blinding Issues – an RCT study is only valid if it properly blinds both subjects and treatment condition providers to group membership. Of course- who wants to provide or be in the control group? Ineffective blinding “will enhance the response to active therapy and reduce the response to control (treatment), which exaggerates the actual treatment-control difference.  (Enck and Zipfel, 2019)

Breaking news: People at the same clinics, from the same military units, etc. talk to each other. Knowing that the condition you were assigned to is or isn’t supposed to make you better…

More breaking news: Is it realistic that doctoral level Providers won’t know the difference between the active treatment and the control treatment? So much for provider blinding. Won’t that affect enthusiasm and faith, expectancy and effort?

Multisite Samples (Enck and Zipfel, 2019, Schnurr, et al., 2003) may introduce cohort and regional differences

Sample size effects – 10 subjects in a co-relational study (39% shared variance required to reach alpha @ .05) vs 302 subjects (1.3% for alpha @ .05). Leads to Oatmeal Science (Cleveland Clinic review says 5-8% drop in cholesterol from relentless consumption of oatmeal or from 300- 276-285); Furthermore, sample size has an inverse relationship to SD, meaning that large sample sizes reduce the size of the SD, which results in increased computed effect sizes and easier to reach MCID, declarations of treatment response and significance. All this suggests using no larger a sample than necessary to avoid declaring significance when the reality is trivial- but consistently trivial- effects.

Per Enck and Zipfel (2019) the Declaration of Helsinki regarding human subjects research recommends no larger a sample than necessary.

SECTION:  Placebo Effects Issues

Myth:  PTSD tx RCTs show only negligible placebo effects.

Reality:  Non-disability seeking PTSD subjects are uniquely predisposed toward over-reporting treatment benefits

In one PTSD medication trial- average placebo effect size was 1.62 compared to 1.11 for anxiety disorders in general. Twas 1.91 for children and adolescents with PTSD and 1.77 for adults with PTSD (Motta, et al., 2023) (older subject showed lower placebo effects- again, age can be a bias factor).

In another Non-antidepressant medication RCT for PTSD (Hodgins, et.al., 2018), researchers reported no significant treatment effects, but did report very large placebo effects with both self-report, self-rated (1.34) and self-report, BUT clinician-rated CAPS (d= 1.70) measures. Please note that the clinician-rated measure actually showed larger placebo effects than the client-rated measure. Also, the authors note that placebo effects appear to be increasing more recently.

Dawson, et al., 2021 found placebo effects for waitlist at .97 compared to a written exposure paradigm.

Back to my objection to using TAU for CG. McLean, et al., 2022 found a TAU placebo effect of .821

Overall, these effects sizes are massive and reflect a disproportionate tendency of PTSD subjects to over-report EB RCT treatment improvement. The bottom line is that if placebo effects are not properly controlled for, RCT PTSD results must be viewed with extreme skepticism, if not frankly disregarded entirely or viewed as biased, false and misleading.

Myth:  PTSD EBT RCTs use rigorous placebo effects control tools, such as equal therapist time, equal plausibility and equal credibility for the control treatment, etc.

Reality: By far the most common control groups used in the PTSD tx EB are WaitList, Treatment As Usual, No Tx and Minimal Tx. These CGs are likely to enhance nocebo effects (esp if blinding has failed), and when compared, inflate active treatment improvements. (Enck and Zipfel (2019)

(Foa 2018 - 60” total of therapist contact by phone for Minimal Contact Condition/Controls vs 900” total of in-person therapist contact for the active PE conditions- did they meet the equal therapist contact standard?)

Since, placebo effects inflate active tx results, effective, high quality, plausible placebo effects control groups are absolutely essential to proper testing of PTSD treatments, but are very rarely used.

The most appropriate placebo control treatment I know of is Present-Centered Therapy (PCT), created by Schnurr, et al., 2003, specifically to be a placebo effects control group for comparison to Trauma-Focused CBT interventions. 30 weekly sessions with 5 monthly follow-up sessions. All inert components, such as advice giving, coping skills, psychoeducational components, etc. No Prolonged Exposure (PE), no Cognitive Processing Treatment (CPT), no cognitive restructuring, etc.

11 years later, (Frost, et al., 2014) listed 5 studies in which PCT performed close to or better than the Active CBT trauma treatment condition as proof, not that CBT research is not controlling adequately for placebo effects or that CBT effects are substantially nonspecific/placebo effects, but rather that PCT is a truly effective NTF, alternative treatment for PTSD. “You don’t have to deal with traumatic memories to effectively deal with trauma.” Avoidance, anyone?

CBT active treatment conditions have either barely beat out, gotten tied by or were edged out by PCT on a number of subsequent studies as well. (e.g., Belsher, et al., 2019, McLean, et al., 2022, Johnson, et al., 2021, Litz, et al., 2019, Lely, et al., 2019, 2021, Foa, et al., STRONGSTAR 2018,)

VS Foa, SS, 2018.  Began with a Minimal Contact CG using 4-15” weekly telephone calls, but quit using it partway through after conducting a preliminary comparison to a Massed Prolonged Exposure condition. PCT was used throughout.

The active tx PE conditions were Spaced= 10 sessions over 8 weeks vs Massed= 5d/wk for 2 weeks). 10 sessions IS the general norm for the PE paradigm. PCT, validated on 35 sessions, was reduced to 10 weekly sessions. On that basis alone, one might expect PCT to perform quite poorly, exaggerating active PE treatment results when compared.

But, when reporting results, SS listed PCT as just another active tx rather than specifically as a CG for comparison to CBT/PE. Mean decreases from baseline were as follows:

PCT                 7.31

PE spaced       7.29

            PE massed       7.13

MCC               3.43 (48% of PE-Massed effect. Met Minimal Clinically Important Difference (MCID) threshold for declaring treatment response. The 40 MCC subjects were then given their choice of the other 3 treatments following their 2 week follow-up. NOT randomized. Unknown how much their “improvement” affected post-tx scores on the active txs)

SS Used ideal low scoring, highly improvement-motivated subjects with careers to protect and, again, compromised the effectiveness of the placebo effects control group PCT by using PCT at less than 1/3 of the sessions it was validated on- and PE still couldn’t win.

Notably, other placebo effects control groups, such as Stress Management vs Cognitive Restructuring have been tried with similar results (e.g., Barhoma, et.al., 2021)

In apparent response to Foa/STRONGSTAR’s 2018 admittedly “modest” results for PE (null in comparison),STRONGSTAR Peterson, et al., 2023 – went Multisite and increased PE from 10 to 15 sessions - despite the potential for each of these changes to induce more bias/placebo effects (Enck and Zipfel, 2019). Using what is called a Non-inferiority Design, they dropped PCT and had no CG at all. If you can’t beat ‘em, avoid ‘em.

Frank (1961) and Enck and Zipfel (2019) state that therapist-subject interaction time must be equal between active vs control conditions. This prevents differences in therapeutic alliance from skewing results in favor of the treatment condition receiving the most interaction. With respect to therapist variables, the therapist’s interpersonal and social skills are related to placebo effects. (Enck and Zipfel, 2019) So, who is chosen to do the CG vs the AT also matters.

Patient preferences for format and mode of therapy will also often generate placebo effects as they affect the expectations a patient- and the provider- have for improvement. (Enck and Zipfel 2019)

Finally, I would assert that the EB’s too-near-to-universal avoidance of plausible, placebo-controlling, nocebo-avoiding CGs by itself says something pretty damning: they know better than to compare their expensive/lucrative manualized, but ineffective research treatments against any tx of any value- placebo or otherwise.

Myth:  Manualized treatment is superior treatment

Reality:  (Truijens, et.al., 2018) analysis looked at six studies directly comparing manualized and non-manualized tx. Found one study supported manual superiority, three reported non-inferiority and two reported non-manualized superiority. They then looked at 8 meta-analyses comparing manualized txs to control groups. 3 supported manualized tx, but 5 did not. It should be noted that the control conditions were weak and included no treatment and waitlist as well as minimal treatment groups (and thus exaggerated manualization’s effects). They then cited one more meta-analysis addressing manual adherence as an indicator of manualized efficacy, which found no effect on outcome for manual adherence.

The authors do note that the more recent comparisons have been similarly inconclusive on the whole.

They also suggest that PTSD’s co-morbidity reality is in direct conflict with the single condition with a single treatment format most compatible with the RCT design. They also noted that the APA and the NIMH both stipulate the use of manuals in clinical practice, despite such data. So much for abiding by the evidence.

IMHO “Compensation (for inadequate training/skills) by manualization” is a bad joke, as is the “trickle down theory of expertise,” where a clinic is headed by a doctorate but staffed at lower levels of education. Quality treatment requires a quality, competent therapist. Find that in the EB! Again, do not look for that which you (or your funding source) do not wish to find.

Reality:  Manualization is de facto required by the RCT format which purportedly provides the highest quality of research evidence (IF it were being properly blinded and bias and placebo controlled). Not to mention that manualized treatment is the shortest, most mass-producible treatment format which can be invalidly justified by high-bias, placebo-infused research and presented as adequately effective and deliverable by the least experienced, cheapest providers. “Doing less for more using cheaper.”

Reality:  Comprehensive tx, multiple co-morbidities needing effective tx, the realities of Assimilative homeostasis until Disconfirmation (with resistance) until Disequilibrium (with resistance) until Accommodation + Consolidation beget a new homeostasis) cycles and the repetitive periods of intensified resistance involved with real change, plus clients’ social support system’s resistance to change - require treatment individualization and unpredictable amounts of therapist interaction and time.

Add in the existence of extinction bursts (when Disconfirmation or Disequilibrium are followed by intense efforts to re-establish previous Assimilative realities and habits) and similar relapse bursts during Accommodation and Consolidation to this and the unpredictability factor in any real change process skyrockets.

Myth:  E-Based CBTx for PTSD is comprehensive and effective. It’s all you likely need to do.

Reality:  IF EBTx were truly comprehensive and effective, residual sxs would be rare and minimal. However, the EB actually says otherwise:

(Held, et.al., 2023)  between 14-50% of those undergoing EB treatment for PTSD could be classified as only minimally or partially responsive. They also add that 2/3 of participants in EB CBT treatment studies retain their PTSD diagnosis. Similarly, (Steenkamp, et al., 2015) – 60-72% PE and CPT retained dx (assuming they actually had full-blown PTSD to begin with).

So, which symptoms tend to remain at significant levels after EB CBT? (Larsen, et.al., 2019), (Hall, et.al., 2021), (Walters, et.al., 2020), (Taylor, et.al., 2020), (Cox, et.al., 2023), Held, et al., 2023), (Schnurr and Lunney 2019), (Tripp, et.al., 2020, 2021).

Re-experiencing, detachment, objective sleep indices, insomnia, nightmares, daytime sleepiness, self-blame, guilt, body image distortions, fatigue, hypervigilance, hyperarousal, persistent avoidance, inability to experience positive emotions, difficulty concentrating, exaggerated startle response, irritability/aggression, unsuccessful AUD quit attempts, and higher alcohol intake tended to persist.

The EB for PTSD tx is anything but comprehensive in terms of treatment scope. The general avoidance of co-morbidities in the RCT format alone indicates that.

Reality:  Once again, the Foa 2018 SS PE study, the greatest mean improvement by an admittedly very small margin was PCT, specifically designed to be a placebo control condition for TF-CBT studies.

Finally, Bhattacharya, et al., 2023  Meta-analytic studies using more and more rigorous bias/placebo corrections, found an aggregate effect size for valid CBT RCTs for PTSD (7 in 5 years!) to be 0.14, but they included the Foa StrongStar 2018 study I’ve been criticizing for sampling biases, low mean pre-test scores and failure to list and use PCT as a primary control and comparison group during analysis. The SS study was also somehow listed as producing an effect size for PE of +.11, despite the data showing the control group PCT edging out both forms of PE. They have not responded to repeated attempts for clarification.

In all fairness to the EB for CBT for PTSD @ 0.14, the aggregate effect size of similar “EB” tx for depression was even worse at 0.09. BTW, others have noted decreasing effects for CBT for depression (e.g., Johnson & Friborg, 2015)

Bottom Line: Valid EB RCT research for PTSD PTX must always include EFFECTIVE controls designed to minimize or correct for bias due to sampling, blinding and CG issues, along with attendant placebo and nocebo effects problems. This is hardly ever done- on average, in less than 10% and perhaps as little as 2-3% of EB PTSD studies - but without controlling for these inflationary effects, we end up with drastically inflated active treatment results and an invalid EB. The rather miniscule low-bias, properly placebo-controlled EB alone shows that CBT EB techniques for treating PTSD actually do very little (0.14) - and sometimes nothing (Foa SS) or worse- to help. End result: we are left scientifically ignorant as to how to truly help real clients with true PTSD, esp. those more severely trauma-adapted. We also have no idea just what the ceiling is for PT improvement.

Further, the inflated-results RCT EB research industry absolutely monopolizes the resources needed to explore and discover how to truly and comprehensively help PTA clients and then to disseminate and implement that knowledge. In reality, we have a Gold Painted EB for PTSD treatment, not a Gold Standard one. And that paint is faded, pitted and peeling.

Effective treatment for PTSD and its common co-morbid conditions hasn’t happened despite somewhere in excess of a billion taxpayer dollars invested during decades of effort. It is past time to realize and admit that success with these short term, manualized, CBT “EB” treatments is never going to happen.

Why would CBT RCT researchers persistently resort to high bias and poor control condition tactics? IMO, it has to do with why CBT does not produce the desired results with PTSD in the first place.

First, short term treatments are not long enough to sufficiently practice and internalize new skills and attitudes or complete the Assimilation>Disconfirmation>Disequilibrium>Accommodation+ Consolidation cycles of change in general (e.g., Gros, et al., 2018).

How long does it take to create positive, life-altering changes when beginning with a PT Assimilative- or homeostatic- balance of trauma-tuned brain changes (e.g., Berman, et al., 2020), hypervigilance-corrupted and danger-biased perceptual patterns, behaviors and attitudes? A client must experience sufficient Disconfirmation of these PTAs AND overcome their own natural resistance to changes in their Survival and Safety-based habits before they will become both consciously and unconsciously convinced of the need to change. If they do become so convinced, they then enter the aggravated confusion, groundlessness and discomfort of Disequilibrium. Once Disequilibrium has been entered, how long will it take and how much therapist support and intervention will it take to overcome THAT discomfort and THAT natural resistance before new, non-trauma-based Accommodations emerge? Assuming of course that prosocial Accommodations will emerge spontaneously from a background of entrenched PTAs. Even then, how long and how much intervention will it take to overcome lapses and relapses and to consolidate new, non-traumatic Accommodations to the point where they become automatic, dominant and enduring, even when traumatic triggers pop up?

There are other reasons so-called EBTxs for PTSD fail to produce the desired results.

Traumatic events, when life, limb, important relationships or identity is subjectively threatened, and intense emotional or physical turmoil or pain is present, are written into memory in a uniquely powerful and enduring manner. Traumatic events can be direct experiences or they can be vicarious or witnessed experiences. But, in each case, an intensely energized, multimodal image is formed and recorded. Such event-memories- especially the more directly experienced and intense ones-  are initially accompanied by elevated BDNF, epinephrine, norepinephrine, glutamate, etc. which combine to initiate a burst of intense neuronal and dendritic growth which creates high levels of consolidation and enduring power regarding the traumatic memory being created and in associated memory neurons and brain structures.

This highly energized chemistry also stimulates the enhancement of dendritic and white matter connections between the immediate event and existing memories similar in content or chemistry. This associative “clustering” process both generalizes and augments the inner presence and power of traumatic memories. It also sensitizes the person to the traumatic event and anything resembling it or associated with it, which enhances ongoing awareness of the possibility that the trauma might reoccur. If it’s always throbbing in the back of your mind, maybe you can sense it coming, be able to avoid it and live a little longer or a bit less painfully.

Having said this, PT reactions are not exclusively sympathetic/excitatory and energizing, as the DSM emphasizes. PTAs can also be parasympathetic-dominant and inhibitory. Freeze, surrender, slump, submit. Or both- or alternately- intensely excitatory and intensely inhibitory and depressing.

These energized, enhanced trauma memories and the schema they cluster to form continue to receive excessive amounts of the excitatory neurotransmitter glutamate even once the instigating event has passed. This “glutamate hypertoxicity” then results in an intensified pruning process of other brain tissues and structures following the initial burst of trauma-relevant brain growth. Glutamate hypertoxicity and the pruning process often eventually adversely affect all of the brain structures in the trauma loop, including those structures and neurochemicals which would otherwise inhibit the over-excitement, facilitate prosocial functions, facilitate habituation or permit extinction learning. (e.g., Tamman, et al., 2023, Wen, et al., 2022, Sheth, et al., 2019, Young, et al., 2018)

It is imperative to understand that a PT hyperaroused and hypofrontal brain is a functionally impaired brain which, as PTSD develops, becomes a structurally impaired brain as well (e.g., Kuhn, et al., 2021).

Structurally, the trauma loop consists primarily of the cognitive, rational, emotion-moderating and compassionate prefrontal lobes, the inhibition vs excitement-resolving ACC, the amygdala which stores vivid traces of the intense memory and which activates the stress response system, the hippocampus, which is involved in both regular learning and extinction learning and the white matter interconnections between these gray matter structures (e.g., Goodman, 2018). All these and more are altered by the prolonged glutamate hypertoxicity which characterizes PTSD.

The receptor system for bonding and calming oxytocin is also corrupted (Nawijn, et al., 2019), as is the mirror neuron system (e.g., Penagos-Corzo, et al., 2022, Tan, et al., 2019, Campbell, et al., 2018). Together, these two systems help us calm and allow us to connect, resonate and bond with others and to learn from observation.

In more fully-developed PTSD, neurochemically, the base levels of both active inhibitory GABA and glutamine (Sheth, et al., 2019), the precursor to both inhibitory GABA and excitatory glutamate- drop, while glutamate levels somehow increase. A supercharged engine, but poor handling, sloppy steering and even poorer brakes. Makes for an intense and interesting, if dysfunctional life. 

This loss of prosocial inhibitory power over trauma memories, impulses and emotions bears emphasis. Moreover, the corruption of structures serving habituation and extinction learning (Tamman, et al., 2023, Wen, et al., 2022, Sheth, et al., 2019, Young, et al., 2018) means that trauma memories -are unerasable and that extinction-based treatments such as PE and CPT are unlikely to be effective. The reduced plasticity of the PT brain due to the pruning process also reduces the potentials for learning and change (Tamman, et al., 2023).

These enhanced, hyperactive trauma memories basically serve to drive and maintain post-traumatic adaptations well after the causative event(s) has passed in the outer world. In the inner world, traumatic events never pass. Peace of mind can become increasingly hard to find. Trauma lives on in memory, whether the specific memory is consciously recallable or not. If trauma memories did die, then how is it that they can be triggered?

To make matters worse, hyperarousal compromises sleep (e.g., Taylor, et al., 2020). Stress chemistry inhibits sleep chemistry (e.g., Hirotsu, et al., 2015). Sleep is when the body and brain do most of their cleansing, balancing and repair activities (e.g., Kim, et al., 2015). But, deep sleep- when these cleansing and repair activities peak- also means you stop hearing and responding to what is going on around you. Yet, in a world described by your worst and strongest memories, losing track of the environment may mean being harmed again or perhaps even losing your life. PT chemistry thus trades your future health for you surviving the present as depicted by, intermingled with and predicted by your worst, strongest memories.

These traumatic memories and adaptations operate at all levels of conscious awareness, including within the unconscious mind and during sleep. Cope, distract and rationalize all you want in order to manage conscious distress while awake, but sooner or later, you will fall asleep and the intense trauma memory-defined inner world will become your experiential world.

Ultimately, the trauma memory image-driven, hyperaroused, under-controlled brain and body may easily become the new, Post-Traumatic homeostasis – the new basis for Assimilation- awake and asleep (e.g., Kuhn, et al., 2021).

Myth:  One can defeat the Unconditioned, natural effects of trauma by addressing Conditioned Stimuli and Conditioned Responses (such as “cognitive distortions”) and treatment may productively avoid the internalized Unconditioned Stimuli known as traumatic memories (e.g, Frost, et al., 2014)

Reality:  Internalized Traumas are living, internal Unconditioned Stimuli and most post traumatic sxs are really just automatic, trauma-adaptive Unconditioned Responses (Avoidance, Re-experiencing, Hyperarousal/Hypervigilance). This Unconditioned, natural, automatic status is also why PTSD sxs are uniform enough for us to create a diagnostic category in the first place.

Now, we DO have PT Conditioned Stimuli and Conditioned Responses such as Cognitive distortions and verbally expressed dysfunctional beliefs. Conditioned stimuli and responses, however, gain their power from being associated with Unconditioned Stimuli, emotions and Responses- not the other way around. CSs and CRs may support the operation of the Unconditioned, yes, but ultimately PTAs are driven and maintained by the Unconditioned Stimuli- the trauma memory(ies).

The brain primarily processes traumatic and negative emotions in the subcortical amygdala, even in the face of active cortical, cognitive strategies and demands (Lee, et al., 2021). Similarly, the phenomenon of amygdala hijacking (Raio, et al., 2013) wherein traumatic cues trigger the amygdala into using its interconnections to the prefrontal cortex to actively inhibit the cognitive control regions casts doubt on the reliable, enduring or generalized effectiveness of using cognitive strategies to control emotional responding in PTSD patients.

Supporting the contention that trauma-impaired brains have difficulty learning and effectively combating PT emotional impulses, it has been repeatedly shown that Intact brains (with intact cognitive skills), unaffected by chronic glutamate hypertoxicity and structural and connectivity deficits, perform better than non-intact brains in both CBT and medication trials (e.g., Etkin, et al., 2019, Bryant, et al. 2008a&b, Corrigan and Hull, 2015, Carnevali, et al., 2018, Duval, et al., 2020, Etkin, et al., 2019, Falconer, et al., 2013, Fan, et al., 2020, Haaland, et al., 2016, Joshi, et al., 2020, Klumpp, et al., 2014, Li, et al., 2015, Malejko, et al., 2017, MinlanYuan, et al., 2017, Scott, et al., 2017, Sheynin, et al., 2020, Stoycos, et al., 2023, Thompson, et al., 2015, Wild and Gur, 2008, Yuan, et al., 2018, Zhutovsky, et al., 2019).

Myth:  Technique is the primary driver of positive life change.

Reality:  Therapeutic relationship, attachment repair, the cultivation of hope and creation of positive memory images and other “nonspecific factors” are clinically far stronger than CB technique (see e.g., Hill and Norcross, 2023, Norcross, 2011 )

Associated Mini-myth:  What works in the office will transfer to and work anywhere in       vivo   

Reality:  By design, most therapists’ offices lack trauma cues and triggers. It’s not the street, the combat zone or one’s traumatic childhood home.

Reality:  Attachment and Social Support Issues in session with the therapist may be very different than those in the client’s outer world.

Social support is very important to both peri-traumatic and PT resilience and recovery (Campbell, et al., 2019). Social support, however, can be disrupted by even the most positive client changes. The AhDrDr(A+Cnewh)cycle applies here and resistance to client change among close relationship folk is hardly unheard of.

IMHO, optimal recovery from PTAs will require addressing unwanted brain and biochemical changes, creating and practicing healing alterations to the troubling memories and dreams which drive and maintain PTAs, calming hyperarousal and over reactivity, normalization of perception and mood, restoration or cultivation of secure attachments and healthy interpersonal skills and relationships, properly dealing with guilt and spiritual issues and adequately healing the host of co-morbid conditions (such as depression, chronic pain and substance abuse) which routinely accompany PTSD. No single technique will cover all these areas of concern. No 5 to 15 session manualized mini-treatment which avoids any significant measure of distressing, schedule-busting and discouraging disconfirmation and disequilibrium will facilitate deep and true change.

The PTSD tx EB, once corrected for bias and control group deficiencies (0.14), confirms precisely this.

Alternatives: 

If researchers and their funding bureaucracies just continue doing as researchers and their funding bureaucracies have been doing and currently continue to do, we will never find out with any scientific certainty just what the upper limits are for therapeutic improvement and just what  needs to happen and in what order for optimal results to be realized. Again, the government funding agencies and those in the research, academic and insurance industries who benefit from their agenda do not look for what they do not want to find. They have also endured and ignored decades of justified criticism.

Treatment

As ST has proven a poor candidate for effective treatment of chronic PTAs, time to try Long term.

With heterogeneity of PT responses, multiple co-morbidities and as manualization demonstrates no superiority, time to try individualized.

As Trauma Memory drives PTA: work with their memory and dream images- the trauma as written in our clients’ heads- in an Evolving, Reparative manner and associate repair images by repetition with existing traumatic imagery. Reparative imagery also tends to evolve with practice- sometimes unpredictably. ST and manualized cannot handle this. Need flexibility.

Reparative memory: Do memory reconsolidation processes update amygdala memory or only cortical memory? Neither? Both? Does repetitive association alter or only associate with subcortical memories? I do not believe we know.

Hypnosis (for enhancement of reparative imagery effects, not for forced memory recovery)

Also, with the two dozen or so clients we had the opportunity to use Neurofeedback Training (NFB) with at the federal prison– to my knowledge, zero recidivists.

Why NFB? The PTA brain functions poorly in cognitive control over emotion, in habituation, in extinction learning, in cognitive learning. Stays hyperaroused 24/7. Its chemistry prevents quality sleep and the restoration of mind and body which concentrates during deep sleep. The PT brain has to normalize into adequate functioning and flexibility. Again, intact brains learn best and respond to treatment best. Nfb training is, in my experience, the single most effective way of achieving this.

NFB Training retrains brain function via operant conditioning and as such, is more effective and enduring than simple Stimulation Exposure Techniques such as Alpha Stim, Audio-Visual devices, Aromatherapy and Transcranial Magnetic Stimulation.

Team approach – no one therapist has all the needed skills

Teach students about optimizing the therapeutic relationship beyond mere Rogerian Level 3 interpretations or manual adherence

Teach students how attachment styles (both their own and clients’) affect therapy quality and process. Teach students how to become a secure base from which distressing memories and other unpleasant realities can be therapeutically addressed. Teach students how to restore or create clients’ attachment potentials in the service of building their capacity to form, maintain and thrive in healthy relationships and social support.

Research

Basically, involve clinicians heavily in the treatment research process instead of shutting them out. We need real world Client and Clinician driven treatment and research methodologies. We are not duplicating the rigor of the medication RCT in psychotherapy RCTSs anyway- and we may never be able to do so to the degree necessary to duplicate the scientific purity and double-blinding of the medication RCT paradigm. AND, even if we could and did, just how appropriate is a single-dx, single short, fixed treatment model given the co-morbidity, relational and complexity issue of PT adaptations and PT psychotherapeutic change? It’s well past time to adapt our research methodology to reality and stop trying to adapt reality to some entrenched, but unrealistic RCT research methodology.      

I propose that a real-world Trauma Clinicians’ Database be created for trauma treatment. We also need Clinician-focused discussion groups and some mechanism for sharing information about what real clinicians find to really work with real clients in the real world.

Also, Meta-analyses of the current EB could help us to derive a set of formulae for calculating correction coefficients for specific sampling biases, other design and measurement biases, and control group nocebo and placebo effects in PTSD research.

Using these derived coefficients, the existing research EB could then be reviewed and corrected for inflationary shortcomings. Once corrected, techniques, programs or other treatment variables which still show SIGNIFICANT positive gains could be identified and reported in a new journal or website established for posting validated findings.

These bias and placebo effects correctives could also be applied to future formal experimental trials AND to aggregated case studies and similar clinical designs in lieu of separate control groups, saving scarce research funds. It would also allow contributed single case data from verified clinicians as well as group research data to be critically assessed for real effects. Incorporating data from practicing clinicians and their real-world clients into a Trauma Clinicians’ Database would both open up the EB to the real world and stimulate clinical innovation rather than counterproductive clinical standardization (and stagnation). Techniques and clients would just need to be well described using clinician-recommended procedures, assessment measures, data reporting schedules and formats for reporting.

This TCD could then be open to both researchers and academicians seeking to mine the data and clinicians seeking to more effectively match interventions to both groups and individual clients. Clinicians could also identify especially productive skills, techniques and theories to guide their professional development efforts.

We would also ultimately be able to identify just how much positive change is possible and which traumatic characteristics and which PTAs seem to limit change and in what ways and in which realms of functioning. We would also be able to analyze different treatment combinations for the incremental benefits of constituent treatment components. Does adding this to that help clients with a particular symptom, severity and co-morbidity profile? Does doing this first make doing that later work better? E.G., Does neurofeedback make a significant contribution, at what treatment lengths and frequencies, at which point(s) in the process and with whom?

Not imposing gross restrictions on the duration of treatment, we could give longer treatment durations a fair evaluation, especially with more chronic, more co-morbid and more symptomatic clients. If anything, the current EB in PT tx- once corrected for inflationary influences- indicates that we are not doing enough of what really needs to be done for anywhere near long enough to create and solidify truly life-improving accommodative changes (again, 0.14 or less).

In this hypothetical TCD, we would not be demanding manualized tx (only well-described techniques and sequences, both initially and session-by-session). This would also allow us to shift the focus of training from memorizing mini-manuals onto a deeper appreciation and understanding of the therapy process, the therapeutic relationship and engagement, the heterogeneity of responses to attachment trauma, physical and sexual trauma and combat trauma and accident/disaster trauma. We could also examine a broader range of techniques and theories.

It would help us train therapists instead of writing myopic, lockstep mini-manuals for hypothetical single diagnosis PT clients in low to moderate distress.

This proposed Trauma Clinician’s Database approach would allow for an assessment of Individualized treatment. With over 20 known mental health PTSD co-morbidities and a similar host of co-morbid medical conditions such as depression, chronic pain and mTBI to treat along with PTSD, individualization of treatment needs a fair evaluation. Informed flexibility, not adherence to some single or dual diagnosis mini-manual is what we, our profession and our PT clients need.

Also, Prediction and theoretical understanding are best based upon real world observation which has been subjected to- and structured by- reflection and open, and at times critical, discussion. But, without adequate and sufficiently varied clinical experience to use as data for reflection, debate and theory-building…

Finally, an Einstein quote and a paraphrase of a second Einstein quote:

1)    Insanity is doing the same thing and expecting different results.

2)    No problem was ever solved by the same minds who created it.

It’s time to let new minds address the problem in new ways.