PTSD and exposure therapy
Today, I present an article and two comments on it. All three speak to the efficacy of exposure therapy. Rubenstein, Duek, Doran & Harpaz-Rotem (2024) published “To Expose or Not to Expose: A comprehensive perspective on treatment for posttraumatic stress disorder” in American Psychologist. Here are the edited abstract and impact statements:
For over 30 years, exposure-based therapies have been considered to be the gold standard in treatment for posttraumatic stress disorder (PTSD), leading to widespread public investment in the dissemination of these therapies. Recent findings have called into question both the effectiveness and the centrality of exposure in treating PTSD. [E]ffectiveness and implementation data show that a large proportion of patients who undergo exposure therapy retain their PTSD diagnosis, and implementation studies have shown low engagement and high dropout rates. Meanwhile, non-trauma-focused therapies have shown promise in treating PTSD. In this review, we aim to answer the question of whether exposure is necessary to treat PTSD by integrating clinical and research literature from multiple perspectives. We review the roots of exposure therapy in both psychodynamic and behavioral paradigms and their proposed mechanisms. We then review non-trauma-focused treatments and their proposed mechanisms. We conclude that the specific form of exposure required by PE [prolonged exposure] is not necessary for symptom remission. Finally, common psychotherapy factors may facilitate patient self-directed exposure outside of the therapy context. These findings should alter the direction of clinical research to identify the therapy processes that most effectively promote the processing of trauma memories. With respect to clinical practice, shared decision-making should allow for increased patient autonomy in choosing either trauma-focused or non-trauma-focused treatments.
This article integrates clinical and research literature on the role of exposure in processing traumatic memories in order to elucidate this controversy and further inform clinicians, researchers, and trainees. It also provides a pathway for future directions in clinical and basic research on PTSD.
Brown (2024) published “Refreshing, Necessary Exposure to the Problem with Exposure Therapies for Trauma: Commentary on Rubenstein et al. (2024) in American Psychologist Abstract
In this invited commentary, I address what I see as the major contributions Rubenstein et al. (2024) have made to challenging the hegemony of exposure therapies for trauma-exposed persons. These include a thorough review of the history of the rise of exposure therapies, the identification of posttrauma responses as forms of anxiety disorders, and an extensive discussion of the neurobiology of the trauma response. Additionally, Rubenstein et al. expose the very high dropout rates in studies of exposure therapies and ways in which many traumatized people have not found them helpful. This article brings the so-called “gold standard” back to its rightful position as one possible, occasionally helpful way of assisting some, but not all, traumatized people.
Najavits (2024) published “Beyond Exposure: A healthy broadening of posttraumatic stress disorder treatment options: Commentary on Rubenstein et al. (2024)” in American Psychologist. Abstract
This commentary on Rubenstein et al. (2024) applauds their sensitive historical exploration of exposure therapy for posttraumatic stress disorder (PTSD) and balanced review of the strengths and weaknesses of that approach. I offer five points to expand on their contribution. (a) Stringent exposure therapy workforce requirements limit scalability, thus restricting access for the large number of patients in need of PTSD treatment. (b) There are additional non-trauma-focused approaches that show efficacy for PTSD. (c) Results of exposure therapy trials should be interpreted in light of how much the study designs align with real-world conditions. (d) Some surprising results from the subfield of PTSD/substance use disorder could suggest new treatment options. (e) There is a need for stronger reporting of clinical worsening (iatrogenesis) outside of clinical trials.
I liked the article and the comments for several reasons. First, I think the reminder that exposure therapies derive from psychodynamic and behavioral paradigms is helpful, given alternative theoretical perspectives that can drive clinical decision making.
Second, there is far too little research that identifies the limitations of therapies that have been declared the “gold standard.” If there are high rates of low engagement and dropout and many people retain the PTSD diagnosis, how effective is it? The last comment about iatrogenesis is important since clinicians should aim to do no harm. Third, I like both Brown’s reference to posttrauma responses as forms of anxiety disorder and Najavits’ reference to the subfield of PTSD/substance use disorder.