The Wild West of PTSD Treatment: Looking Beyond Evidence-based Therapy

graphic of a magnifying glass with a question mark over documents
PHCoE graphic
By Erin Beech, M.A.
February 12, 2018

Treatment of posttraumatic stress disorder (PTSD) is an urgent and important priority for the U.S. military. We have evidence-based treatments that work for many people with PTSD, which include prolonged exposure therapy and cognitive processing therapy, among others. But some who undergo these treatments do not achieve remission, and some are unwilling to participate in or drop out of these treatments. For a number of reasons, service members experiencing PTSD may be looking for alternatives to the existing evidence-based treatments for PTSD.  Maybe they tried one of these treatments and didn’t feel that it worked for them. Maybe the idea of one-on-one weekly therapy is daunting or just unpleasant.

There are a number of complementary and alternative therapies proposed for PTSD that do have emerging evidence, though not all of it is promising. And there are a large number of treatments that show up in the media that have no research whatsoever to stand on. Evidence-based treatments aren’t flashy or sexy, and the media often highlight novel treatments that may not be considered treatments at all. Some of the more out-there treatments for PTSD covered by the media in recent months include: sweat lodge vision quests, therapeutic fishing, parrot husbandry, and shark dive therapy.

Articles covering these treatments often feature anecdotes of individuals with PTSD whose lives have been greatly improved. While these stories can be heartwarming, it is important to realize that, without evidence, there is no basis for suggesting that the same experience will be true of others who seek out these same experiences.

Many of these proposed treatments are activities or experiences that any individual can participate in, many of which involve the outdoors (e.g. “wilderness therapy”), animal interaction (e.g. “wolf therapy”), or adrenaline highs (e.g. skydiving). Other treatments covered in the media that lack an evidence-base are created by individuals or groups that advertise via a website, often charging money for how-to manuals, devices, or for receiving the treatment itself. These websites can be misleading, as the treatments appear to have been developed by reputable clinicians, and the websites may include testimonials and depict “studies” that appear to be published research, but are not (or, if they are published, they are often low quality studies published in low impact journals).

It is important to critically evaluate what you read online. While novel treatments that you may encounter in the news may sound exciting and promise a quick fix, remember that these treatments have not been properly examined.

Hopefully you are keeping up with our PHCoE Psych Health Evidence Briefs which provide scientific evidence and clinical guidance for treatment topics chosen by our blog readers and website users. In an effort to respond to requests for evidence briefs on unsubstantiated treatments, we have created a place to identify treatments for which there is no research evidence. In the future, when evidence brief topics with no evidence are submitted, our team will conduct a search to ensure that no research studies exist, and then we will add these to our list. You can find the list on the Treatments with No Evidence page – come back often, as the list will be updated any time one of these  is identified and of course the list will be revised as well if one develops an evidence base, such that we can produce an evidence brief.

For submitted topics that have research evidence, we’ll continue to release new briefs every few months, including the latest set on biofeedback for posttraumatic stress disorder, repetitive transcranial magnetic stimulation (rTMS) for major depressive disorder and client-centered therapy for major depressive disorder.

Ms. Erin Beech is a contracted senior research associate at the Psychological Health Center of Excellence. She has a master’s degree in psychology and has expertise in evidence synthesis and is responsible for drafting the Psych Health Evidence Briefs.


The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.


Comments

  • Although this is not necessarily evidence based, after 30 years doing psychotherapy for vets and others with PTSD, I found that after about 2 years of a client being in weekly or biweekly individual therapy, and maybe some couples and group counseling, some did not improve much. After studying with the Modern Psychoanalytical Institute, I learned what I had not had in graduate school. Most of these types of vets and others had much earlier traumas, many times pre-verbal. Addressing their adult traumas of war or rape were not getting into these deeper ingrained traumas. I had to do a bit of adjusting for transference, negative and positive that brought out these earlier traumas. This is long term hard work and they do little training in this mode in graduate schools. Its not that you abandon the cognitive behavioral, or exposure therapy. It gets you in the door with traumas that are more easily accessible. Then you either settle for a reduction in some of the intrusive and avoidance symptoms and cut them loose, refer them to more analytical therapy, or get some damn good supervision if you are keeping them, and do some more studies.

  • “While these stories can be heartwarming, it is important to realize that, without evidence, there is no basis for suggesting that the same experience will be true of others who seek out these same experiences.” I say the same is true with evidence-based modalities and with medications. Prazosin, for example, has worked well for nightmares in the majority of patients I see. Yet, a recent study reported it was not effective! Plus, I’ve had to hospitalize Soldiers going through some types of therapy, especially PET.

    So why doesn’t the military study some alternative modalities? In behavioral health a great number of patients complain about physical problems and the lack of effective care. In addition to PT, where Soldiers wear black uniforms, run in the dark, on pavement, and at the worst time of the day for physical exercise, why not also train them in Tai Chi, which tends to help both physical and mental conditions. It’s the only thing that keeps me going as a behavioral health provider.

    At one point I veered off the usual pathway and studied Chinese medicine philosophy, Tai chi, Qigong, and even became a Zen Shiatsu instructor. One of my best patients was my wife, who has fibromyalgia. I worked on her regularly and she earned a 3rd degree black belt in Hapkido, right alongside me.

    At the Asian acupuncture school where I taught Zen Shiatsu I was able to receive free acupuncture from students when they had openings. Admittedly it never did much for me except relax me. However, I developed a case of bilateral tendonitis in my elbows and suffered for a year. My ortho doc had nothing left to do but surgery and she didn’t think that would do much. One of the students at the school was a family-trained acupuncturist from Korea who was training in the states in order to obtain certification and work here. His needling knocked out the pain in one elbow in one treatment and the other with the second treatment. I have never had a problem since.

    I went even further off the recognized path and trained as a shamanic practitioner with a psychologist/medical anthropologist. I was shocked at the number of physicians and psychotherapists who were there with me. Most said they were there because they finally wanted to be able to help others. One therapist swore off talk therapy. A psychiatrist told me he wanted to help his peers who were committing suicide.

    My own PTSD decided it didn’t want to reside in me any longer, after a rough all-nighter in the Amazon jungle where I fought every demon I ever had. The only residual effects that remain are an aversion to loud noises and being aware of what happens around me. I’ll settle for that!

    So when will the military step up and get it’s own evidence?

Add new comment

PHCoE welcomes your comments.

Please do not include personally identifiable information, such as Social Security numbers, phone numbers, addresses, or e-mail addresses in the body of your comment. Comments that include profanity, personal attacks, or any other material deemed inappropriate by site administrators will be removed. Your comments should be in accordance with our full comment policy regulations. Your participation indicates acceptance of these terms.

Please read our full Comment Policy.

You must have Javascript enabled to use this form.
You must have Javascript enabled to use this form.