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Cited by 199Posttraumatic Stress Disorder ResearchPsychotherapy Techniques and ApplicationsPsychoanalysis and Psychopathology Research

The DOI matches its Crossref record; 73 of the 73 references it cites were found in a registry or an index.

Do all psychological treatments really work the same in posttraumatic stress disorder?

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Ehlers, Anke, Bisson, Jonathan, Clark, David M., Creamer, Mark, Pilling, Steven, Richards, David, Schnurr, Paula P., Turner, Stuart, Yule, William·2010·Clinical Psychology Review
DOI 10.1016/j.cpr.2009.12.001PMC PMC2852651
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Abstract

A recent meta-analysis by Benish, Imel, and Wampold (2008, Clinical Psychology Review, 28, 746-758) concluded that all bona fide treatments are equally effective in posttraumatic stress disorder (PTSD). In contrast, seven other meta-analyses or systematic reviews concluded that there is good evidence that trauma-focused psychological treatments (trauma-focused cognitive behavior therapy and eye movement desensitization and reprocessing) are effective in PTSD; but that treatments that do not focus on the patients' trauma memories or their meanings are either less effective or not yet sufficiently studied. International treatment guidelines therefore recommend trauma-focused psychological treatments as first-line treatments for PTSD. We examine possible reasons for the discrepant conclusions and argue that (1) the selection procedure of the available evidence used in Benish et al.'s (2008)meta-analysis introduces bias, and (2) the analysis and conclusions fail to take into account the need to demonstrate that treatments for PTSD are more effective than natural recovery. Furthermore, significant increases in effect sizes of trauma-focused cognitive behavior therapies over the past two decades contradict the conclusion that content of treatment does not matter. To advance understanding of the optimal treatment for PTSD, we recommend further research into the active mechanisms of therapeutic change, including treatment elements commonly considered to be non-specific. We also recommend transparency in reporting exclusions in meta-analyses and suggest that bona fide treatments should be defined on empirical and theoretical grounds rather than by judgments of the investigators' intent.

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Fig. 1 Comparison of individual non-directive treatments with trauma-focused CBT programs. Intent-to-treat analyses for percent remitted (loss of PTSD diagnosis) with treatment. The study marked with an arrow was selected for Benish et al.'s (2008) meta-analysis. Abbreviations: WL/EDU = waitlist or psychoeducation; SUP/PCT = supportive or present-centred therapy; CBT = trauma-focused CBT. Bl03 = Blanchard et al. (2003). Br03 = Bryant et al. (2003). E09 = Ehlers et al. (2009). F91 = Foa et al. (1991). McD05 = McDonagh et al. (2005). N04 = Neuner et al. (2004). Sch07 = Schnurr et al. (2007).
Fig. 1 Comparison of individual non-directive treatments with trauma-focused CBT programs. Intent-to-treat analyses for percent remitted (loss of PTSD diagnosis) with treatment. The study marked with an arrow was selected for Benish et al.'s (2008) meta-analysis. Abbreviations: WL/EDU = waitlist or psychoeducation; SUP/PCT = supportive or present-centred therapy; CBT = trauma-focused CBT. Bl03 = Blanchard et al. (2003). Br03 = Bryant et al. (2003). E09 = Ehlers et al. (2009). F91 = Foa et al. (1991). McD05 = McDonagh et al. (2005). N04 = Neuner et al. (2004). Sch07 = Schnurr et al. (2007).CC BY · PubMed Central
Fig. 2 Effect sizes for changes in PTSD symptoms with treatment for Brom et al.'s (1989) study and for trauma-focused CBT programs (PTSD following trauma in adulthood). In line with Brom et al., effect sizes are based on completers. To ensure the comparison is fair, only studies with similar or lower drop-out rates as in Brom et al. are shown (drop-out rates in parentheses below). However, the pattern would be the same if all trials were shown. Effect sizes were calculated as the pre-post difference in PTSD symptom scores, divided by the pooled standard deviation. Abbreviations: EXP = exposure therapies, CBT = cognitive behavior therapies, Desens = Trauma desensitization, Hypno = hypnotherapy, Psychodyn = psychodynamic therapy; B89 = Brom et al. (1989, 11%). Br08 = Bryant et al. (2008, 17%). E03 = Ehlers et al. (2003, 0%), E05 = Ehlers, Clark, Hackmann, McManus, and Fennell (2005, 0%), E09 = Ehlers et al. (2009, 3%). Fe99 = Fecteau and Nicki (1999, 17%). F99 = Foa et al. (1999, 8%). K03 = Kubany, Hill and Owens (2003; 5%). M98 = Marks et al. (1998, 13%). L02 = Lee et al. (2002, 8%). Ro05 = Rothbaum et al. (2005, 13%). T99 = Tarrier et al. (1999, 11%). V94 = Vaughan et al. (1994, 8%).
Fig. 2 Effect sizes for changes in PTSD symptoms with treatment for Brom et al.'s (1989) study and for trauma-focused CBT programs (PTSD following trauma in adulthood). In line with Brom et al., effect sizes are based on completers. To ensure the comparison is fair, only studies with similar or lower drop-out rates as in Brom et al. are shown (drop-out rates in parentheses below). However, the pattern would be the same if all trials were shown. Effect sizes were calculated as the pre-post difference in PTSD symptom scores, divided by the pooled standard deviation. Abbreviations: EXP = exposure therapies, CBT = cognitive behavior therapies, Desens = Trauma desensitization, Hypno = hypnotherapy, Psychodyn = psychodynamic therapy; B89 = Brom et al. (1989, 11%). Br08 = Bryant et al. (2008, 17%). E03 = Ehlers et al. (2003, 0%), E05 = Ehlers, Clark, Hackmann, McManus, and Fennell (2005, 0%), E09 = Ehlers et al. (2009, 3%). Fe99 = Fecteau and Nicki (1999, 17%). F99 = Foa et al. (1999, 8%). K03 = Kubany, Hill and Owens (2003; 5%). M98 = Marks et al. (1998, 13%). L02 = Lee et al. (2002, 8%). Ro05 = Rothbaum et al. (2005, 13%). T99 = Tarrier et al. (1999, 11%). V94 = Vaughan et al. (1994, 8%).CC BY · PubMed Central

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Research works printed but not linked: 1

  1. Wampold, B. E. (2008). So it's good outcomes from me. And it's good outcomes from him. Is it the treatment or the therapist that works? Closing debate. Paper presented at the Savoy Conference on Psychological Therapies in the NHS, Science, Practice and Policy, London, 27th November 2008. http://www.newsavoypartnership.org/2008conference.htm

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Metadata

Authors
Ehlers, A., Bisson, J., Clark, D. M., Creamer, M., Pilling, S., Richards, D., Schnurr, P. P., Turner, S., & Yule, W.
Affiliations
  • King's College London (GB)
  • Cardiff University (GB)
  • University College London (GB)
  • University of Exeter (GB)
  • United States Department of Veterans Affairs (US)
Corresponding author
Ehlers, Anke
ORCID
Venue
Clinical Psychology Review
Publisher
Elsevier BV
Published
2010-03
Volume
30
Issue
2
Pages
269-276
ISSN
0272-7358 (ISSN-L)
DOI
10.1016/j.cpr.2009.12.001
PMC
PMC2852651
OpenAlex
W2101542507
Cited by
199
References
72
Citations by year
2026: 4 · 2025: 1 · 2024: 3 · 2023: 2 · 2022: 20 · 2021: 10 · 2020: 9 · 2019: 10 · 2018: 16 · 2017: 13 · 2016: 17 · 2015: 22 · 2014: 22 · 2013: 21 · 2012: 11
FWCI
1.36
Type
journal article
Language
en
Open access
Licence
Locations
  • Clinical Psychology Review (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • UCL Discovery (University College London) (submittedVersion)
  • Research Portal (King's College London) (submittedVersion)
Funders
Wellcome Trust Principal Research Fellowship (069777)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
  • Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
Keywords
post-traumatic stress disorder, trauma-focused cognitive behavioral therapy, EMDR, treatment content, meta-analysis bias, natural recovery, non-specific treatment effects, therapeutic mechanisms, treatment guidelines
MeSH terms
Clinical Trials as Topic, Humans, Life Change Events, Psychotherapy, Stress Disorders, Post-Traumatic, Meta-Analysis as Topic, Selection Bias

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