Rethinking PTSD therapy

There is a fundamental controversy in the field of psychotherapy on the equivalence at the level of effectiveness of different therapeutic procedures. While it is true that common factors are probably major in explaining the variance, it is likely that, especially in certain disorders, there are procedures more effective than others (ie, therapeutic factors has been confined to the technique), and even some procedures are harmful.

In a recent issue of Clinical Psychology Review addresses the controversy surrounding posttraumatic stress disorder (PTSD). A couple of years, a review in the same journal (Benish et al, 2008) concluded that all bona fide treatment is effective in this area, now, Ehlers et al. (Clinical Psychology Review 30 (2010) 269-276) review methodological errors (including biases in the selection of studies, the need to consider sample sizes and effect size, and the need to compare with non-treatment) and review the findings, it seems evident from a broad perspective and exhaustive that trauma-focused treatments (eg cognitive-behavioral trauma-focused, or EMDR, ie, working primarily with the living memory of the traumatic event and its meaning constructed by the subject) are more effective than non-focused in the traumatic event (hypnotherapy, psychodynamic, interpersonal, stress management).

A key emphasis of the authors is the concept cuidadín bona fide (a thing is the subjective assessment that something is intended and face validity to be therapeutic, and one which still has to be some empirical evidence and / or theoretical works, and what works, and this also needs to demonstrate that it is superior to doing nothing).

Traumatic contexts, fortunately in most cases people do not need psychotherapy, but their resilience own healing resources allow. However, we often observe a default presence of psychological services that come ready to intervene on the victims of disasters. It is possible that the actual operating be sensible and reasoned, but it appears that today, many organizations (Red Cross, Civil Protection) continue to rely on a technique for emergency intervention / prevention (within 48 hours after the traumatic event) debriefing call, curiously, is not only ineffective but counterproductive in some cases (Rose et al.: Cochrane Database of Systematic Reviews 2002, and the review above).

So first, we have that most people do not develop PTSD (and without professional help psychotherapy can be so redundant and narcissistic fluoxetine these recipes when you leave the girlfriend). Second, for those who need therapy are procedures with different levels of effectiveness (and potentially pathologizing any). And finally, the essential question: why the differential effectiveness?.

A few months ago, an article in Nature entitled Preventing the return of fear in Humans Mechanisms using reconsolidation update shows how Schiller et al. (Including LeDoux) work experimentally inducing a traumatic imprint then therapeutically addressed through simple extinction, or through explicit and deliberate revival of fear before the extinction phase (drawing for that particular state of vulnerability that allows for modification prior to reconsolidate again) or at 6 hours or 10 minutes later. It is this latter group that has a missing (deleted) the fear of a highly specific and even held a year later (there are earlier references using substances to induce an extinction of fear memory, but this time it bareback, without drugs ). According to Schiller, the group of the 10-minute rewrites the original traumatic memory trace information of non-fear, the other two simply create a new memory, competing with the traumatic, sometimes it moves but sometimes not, or only partially. Although experimental conditions are obviously working with conditioned fear and not exactly a clinical picture of PTSD can guess wisely, that we do not remember the original event, but rewriting it after the last time they access the memory, and that for a effective therapy is necessary to reactivate the trauma, but not as a mere Freudian catharsis but as a necessary step for us to open the window that allows rewriting the details and significance of memory (in interaction with each other) before rebind (Incidentally, this makes it understandable EMDR mysterious, at least in part).

However, a hasty recovery, accelerated without therapeutic alliance, forced abreaction and verbalisation, and not individually rewritten (more or less what some say would debriefing) may involve a re-traumatization, although this seems to be widely used in psychological interventions in disasters and emergencies (generalized, say some voices):

In view of the contradictory results is likely to ask why this unconditional acceptance. Responses are very different, and perhaps not yet reached a clear consensus, however, does not seem possible to understand the current situation without taking into account interests that go beyond the actual practice of psychology, such as economic and legal interests. In this regard, some authors stress the fact that organizations, banks, hospitals and agencies, they should continue to use this technique because of its low cost compared to others, and the difficulty of developing alternatives (Kenardy, 2000; Paton, 2000; Stuhlmiller and Dunning, 2000a). And thanks to the simplicity of the protocol is possible to use the technique so universal, applying to all types of individuals and groups, regardless of their culture, experience or personality characteristics (Paton et al., 2000) something that greatly reduces the costs.

Poseck Vera B. Debriefing: a review about the current controversy. Journal of crisis. 2004, 3 (2) :7-26.