In a recent article in The New York Times Sunday Review, US Marine Corps Veteran David J. Morris chronicled his experience getting treatment for post-traumatic stress disorder at a Veterans Affairs hospital. In his essay, he detailed his adverse reactions to Prolonged Exposure (PE) therapy, one of the only PTSD treatments to have wide-reaching empirical support.
In PE therapy, individuals are asked to approach — in both imaginary and real-life settings — situations, places, and people they have been avoiding. The repeated exposure to the perceived threat disconfirms individuals’ expectations of experiencing harm and over time leads to a reduction in their fear. The APS journal Psychological Science in the Public Interest last year provided a comprehensive report on PE and other evidence-based treatments.
In a brief online interview, APS asked Harvard University psychological scientist Richard J. McNally, whose lab studies PTSD and other anxiety disorders, to share his observations about Morris’ article and to provide the facts about the evidence for PE’s effectiveness.
APS: As a scientist who has extensively studied treatments for PTSD, what are your overall impressions about the article “After PTSD, More Trauma”?
McNally: David Morris is a former Marine officer who experienced multiple traumatic events as a civilian war correspondent embedded within American combat units in Iraq. He is a thoughtful and excellent writer. Troubled by PTSD symptoms, he sought help at the San Diego VA and received Prolonged Exposure (PE) therapy, the treatment with the strongest evidence of efficacy. Sadly, however, his distress did not diminish during imaginal exposure sessions, and he terminated treatment early. His case is atypical; most patients do benefit, and many recover from PTSD. Although his symptoms apparently worsened temporarily, persistent worsening is very rare for patients receiving PE. One recent study of over 300 female assault survivors revealed that 8.1% of patients on a wait list experienced reliable worsening of their symptoms, whereas none of the patients receiving PE did so. Accordingly, people with PTSD run a greater risk of their symptoms worsening if they do not receive PE than if they do receive it, even though a minority does fail to improve from this treatment. Fortunately, Morris found Cognitive Processing Therapy (CPT) helpful.
APS: Is more research on PE needed, in your opinion? Are there factors about the treatment that we still don’t understand?
McNally: There is no uniformly effective treatment for PTSD akin to antibiotics for bacterial infections. There is no “magic bullet” for curing PTSD, at least not yet. To say that PE and CPT are evidence-based, efficacious interventions for PTSD means that multiple, rigorous randomized controlled trials have shown that on average they are statistically and clinically more effective in diminishing PTSD symptoms than are other approaches. It does not mean that everyone recovers. Accordingly, we still have much room for improvement. For example, clinical scientists have recently discovered that ruptures in the therapeutic relationship that are not repaired can impede progress in PE. This exemplary work shows how researchers can discover correctible problems that can prevent an otherwise effective treatment from working well.