Mind the Gap: What can researchers do to improve the dissemination of evidence-based treatments for PTSD?
September 24, 2013
The Gap Between PTSD Research and Practice
In the past three decades, there has been extensive research into the treatment of PTSD. Results of randomized controlled trials show that psychological treatments are highly efficacious (Bisson et al., 2007). However, not all types of treatment show comparable effects. Specifically, different variants of trauma-focused cognitive behavior therapy (e.g., prolonged exposure, cognitive therapy, cognitive processing therapy) and eye movement desensitization and reprocessing (EMDR) have been found to show the highest effects in reducing PTSD symptom severity (e.g., Bisson et al., 2007). Consequently, these approaches are recommended as first-line treatments in current treatment guidelines (Forbes et al., 2010).
However, despite clear evidence in favor of trauma-focused treatments these treatments are not as frequently used in clinical practice as one would expect on the basis of the evidence and the clinical guidelines (Becker, Zayfert, & Anderson, 2004; van Minnen, Hendriks, & Olff, 2010). This phenomenon is often described as the research-practice gap.
What Can We Do to Bridge the Gap?
A number of means to bridge the research-practice gap in the field of PTSD have been suggested in the literature (for a detailed review, see Foa, Gillihan, & Bryant, 2013). These include the need to provide practitioners with information on evidence-based treatments in order to overcome misconceptions about trauma-focused treatments that are held by some clinicians. In addition, systematic training and supervision are seen as a key factor to disseminate evidence-based treatments. Reassuringly, there are indications that structured dissemination programs increase the frequency of clinicians’ offering trauma-focused treatment to their clients (Karlin et al., 2010).
On the other hand, it appears unlikely that the gap between research and practice can simply be resolved by stepping up efforts at dissemination. In this article, we will summarize five important suggestions from the literature how PTSD treatment research may need to be modified in order to bridge the gap.
Are We Talking About the Same Group of Patients?
One of the barriers for using trauma-focused treatments often reported by clinicians is their concern that the patients included in controlled treatment studies are systematically different from those seen in routine clinical practice and that results from controlled research are therefore not applicable for routine care. The question whether treatments work as well in routine care as they do in controlled trials is ultimately an empirical one that is addressed in so-called effectiveness studies.
In the field of PTSD, only few effectiveness studies have been conducted to date. Reassuringly, results obtained so far show that effect sizes are very similar to those established in randomized controlled efficacy trials (prolonged exposure: e.g., Foa et al., 2005; cognitive therapy: e.g., Gillespie, Duffy, Hackmann, & Clark, 2002). However, in comparison to the large and still growing number of controlled efficacy trials being conducted, research into the effectiveness is still in its infancy, and more research is needed in order to be able to draw definite conclusions regarding this issue.
Suggestion 1: Researchers should conduct more effectiveness studies under routine clinical circumstances.
A frequent concern expressed by clinicians is the idea that patients in routine clinical practice are more “complex” than those included in randomized controlled efficacy trials. For example, many PTSD patients seen in routine settings have experienced childhood sexual and/or physical abuse as their index traumatic event(s). However, this group is under-represented in controlled efficacy studies that form the basis for current treatment guidelines.
For example, 28 out of 38 randomized controlled trials (RCT) included in the frequently cited meta-analysis by Bisson and colleagues (2007) focused on survivors of adult-onset traumatic events only. Similarly, patients with serious comorbidity, including borderline personality disorder, substance use disorder and/or self-injurious behavior, were excluded from most studies the meta-analysis was based on. Reassuringly, there is increasing evidence showing that trauma-focused treatments are also efficacious for PTSD in adult survivors of childhood trauma (e.g., Chard, 2005; Cloitre et al., 2010) and/or PTSD patients with serious comorbidity (e.g., Mills et al., 2012), although some modifications of the standard approach may be necessary (Cloitre et al., 2011). However, the absolute number of trials studying patients with complex symptom presentation is still small.
Suggestion 2: Efficacy studies should focus more on the treatment of PTSD in survivors of childhood interpersonal trauma and/or patients with serious comorbidity.
Can Trauma-Focused Treatment Be Harmful?
Another issue that has been identified as a barrier to implement trauma-focused treatment in routine clinical care is the concern that trauma-focused treatments may be harmful to some patients in that they may result in increased levels of PTSD and/or an increase in self-harming behavior (Becker et al., 2004). As emphasized by different reviews in this area, there is currently no evidence that trauma-focused treatments lead to symptom worsening or an increase in self-harming behavior to a significant degree (see e.g., van Minnen, Harned, Zoellner, & Mills, 2012). However, it should be noted that in most RCTs investigating trauma-focused treatments for PTSD, these issues have not been assessed and reported in a systematic way.
Suggestion 3: In all clinical trials on PTSD, the frequency of symptom worsening and/or increase in self-harming behavior during the course of treatment should be assessed and reported.
Traditionally, there is a clear division of labor between researchers on the one hand (who are responsible for the accumulation of knowledge regarding efficacious and effective treatments), and clinicians on the other hand (who are responsible for offering evidence-based treatments to clients in routine clinical care). According to this traditional model, researchers are responsible for developing new interventions, designing studies and analyzing and interpreting the data, whereby clinicians are solely responsible for the execution of evidence-based treatments in clinical practice.
One can argue that the scientist-practitioner-gap may be a direct consequence of this traditional top-down model of dissemination. Community-partnership research has been suggested as an alternative model, whereby researchers and practitioners join forces in developing, testing, and implementing efficacious and effective interventions (see Becker, Stice, Shaw, & Woda, 2009).
Suggestion 4: Researchers and clinicians in the field of PTSD treatment should join forces, e.g. by establishing practice-research networks.
Suggestion 5: Routine outcome monitoring should take place in routine clinical practice in order to increase the database on the effectiveness of PTSD treatments.
Bridging the research-practice gap in PTSD treatment is an important challenge and a combination of different strategies is likely to be most successful. Researchers and clinicians should join forces to rise to the challenge. Reassuringly, the best evidence currently available suggests that trauma-focused treatments are not only efficacious, but also effective and safe for a large group of patients.
Therefore, the widespread dissemination of trauma-focused treatments is certainly in the best interest of patients suffering from PTSD. On the other hand, there are a number of blind spots in the literature (e.g., frequency of adverse effects; treatment of PTSD populations with serious comorbidity) that need to be addressed in a more systematic way.
About the Author
Thomas Ehring, PhD, is a professor of clinical psychology and psychotherapy at the University of Münster (Germany). In addition, he is a registered psychotherapist (CBT) and director of the Center for PTSD treatment at Münster University.
ISTSS Treatment Guidelines for PTSD, Second Edition
The revised Treatment Guidelines presented in Effective Treatments for PTSD, Second Edition, were developed under the auspices of the PTSD Treatment Guidelines Task Force established by the Board of Directors of ISTSS. The guidelines are based on an extensive review of clinical and research literature prepared by experts in each field and intended to assist clinicians who provide treatment for adults, adolescents and children with PTSD. Available in the ISTSS Amazon store.
Becker, C. B., Stice, E., Shaw, H., & Woda, S. (2009). Use of empirically supported interventions for psychopathology: Can the participatory approach move us beyond the research-to-practice gap? Behaviour Research and Therapy, 47, 265-274. doi: 10.1016/j.brat.2009.02.007
Becker, C. B., Zayfert, C., & Anderson, E. (2004). A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD. Behaviour Research and Therapy, 42, 277-292. doi: 10.1016/S0005-7967(03)00138-4
Bisson, J. I., Ehlers, A., Matthews, R., Pilling, S., Richards, D., & Turner, S. (2007). Psychological treatments for chronic post-traumatic stress disorder. Systematic review and meta-analysis. British Journal of Psychiatry, 190, 97-104. doi: 10.1192/bjp.bp.106.021402
Chard, K. M. (2005). An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. Journal of Consulting and Clinical Psychology, 73, 965-971. doi: 10.1037/0022-006X.73.5.965
Cloitre, M., Courtois, C. A., Charuvastra, A., Carapezza, R., Stolbach, B. C., & Green, B. L. (2011). Treatment of complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress, 24, 615-627. doi: 10.1002/jts.20697
Cloitre, M., Stovall-McClough, K. C., Nooner, K., Zorbas, P., Cherry, S., Jackson, C. L. et al. (2010). Treatment for PTSD related to childhood abuse: A randomized controlled trial. American Journal of Psychiatry, 167, 915-924. doi: 10.1176/appi.ajp.2010.09081247
Foa, E. B., Gillihan, S. J., & Bryant, R. A. (2013). Challenges and Successes in Dissemination of Evidence-Based Treatments for Posttraumatic Stress: Lessons Learned From Prolonged Exposure Therapy for PTSD. Psychological Science in the Public Interest, 14, 65-111. doi: 10.1177/1529100612468841
Foa, E. B., Hembree, E. A., Cahill, S. P., Rauch, S. A., Riggs, D. S., Feeny, N. C. et al. (2005). Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: Outcome at academic and community clinics. [Original]. Journal of Consulting and Clinical Psychology, 73, 953-964. doi: 10.1037/0022-006X.73.5.953
Forbes, D., Creamer, M., Bisson, J. I., Cohen, J. A., Crow, B. E., Foa, E. B. et al. (2010). A guide to guidelines for the treatment of PTSD and related conditions. [Article]. Journal of Traumatic Stress, 23, 537-552. doi: 10.1002/jts.20565
Gillespie, K., Duffy, M., Hackmann, A., & Clark, D. M. (2002). Community based cognitive therapy in the treatment of post-traumatic stress disorder following the Omagh bomb. Behaviour Research and Therapy, 40, 345-357. doi: 10.1016/S0005-7967(02)00004-9
Karlin, B. E., Ruzek, J. I., Chard, K. M., Eftekhari, A., Monson, C. M., Hembree, E. A. et al. (2010). Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. Journal of Traumatic Stress, 23, 663-673. doi: 10.1002/jts.20588
Mills, K. L., Teesson, M., Back, S. E., Brady, K. T., Baker, A. L., Hopwood, S. et al. (2012). Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: A randomized controlled trial. JAMA, 308, 690-699. doi: 10.1001/jama.2012.9071
van Minnen, A., Harned, M. S., Zoellner, L., & Mills, K. (2012). Examining potential contraindications for prolonged exposure therapy for PTSD. European Journal of Psychotraumatology, 3: 18805. doi: 10.3402/ejpt.v3i0.18805
van Minnen, A., Hendriks, L., & Olff, M. (2010). When do trauma experts choose exposure therapy for PTSD patients? A controlled study of therapist and patient factors. Behaviour Research and Therapy, 48, 312-320. doi: 10.1016/j.brat.2009.12.003