Guidelines for the Treatment of PTSD

From Division 35 Council Representative, Debra Kawahara:

Dear Division 35 Colleagues,

As you may be aware, APA has posted guidelines for the treatment of PTSD and plans to develop more guidelines for other diagnoses. A group of APA members, Council representatives, and an activist group of psychologists are voicing concerns about the issues regarding the guidelines. A major concern is that the studies used as the bases for the guidelines do not adequately consider matters of culture, race, ethnicity, SES, as well as using only a narrowly defined criteria for treatment. 

Below is the link to the petition opposing the guidelines, as well as responses to some of the opposition to the petition. I urge you to read both the petition and the arguments supporting it and please consider signing before the next APA Council meeting that begins on March 9, 2018.

Thank you for your consideration.

Respectfully, 

Debra Kawahara

Debra Kawahara, Ph.D. | Associate Dean of Academic Affairs & Professor

California School of Professional Psychology

Alliant International University 
858.635.4613 | dkawahara@alliant.edu| www.alliant.edu
Alliant Confidential Compliance and Safety Reporting System: (866) 290-4245 | www.alliant.ethicspoint.com

Dear Colleagues:

As opposition to APA’s PTSD Guidelines grows – 2479 signatories to the Petition so far (see:https://www.thepetitionsite.com/takeaction/480/492/776/?cid=headerClick)  –  it has become apparent that some misperceptions have occurred and also that some of the reasons for opposing the Guidelines could benefit from further explanation.  This email is intended to address those issues.

Misperception of the Objections to the Use of RCTs as the Basis for the PTSD Guidelines

The petition is not an attack on research nor on RCT as a form of research.  The petition clearly asserts that our objection is to the use of RCTs as the only basis for making “best treatment” decisions. Nevertheless, several commentators on various listserves have responded as if we were disputing that RCTs have value and a role to play in evaluating treatment outcomes.  Therefore the reasons for our position needs elaboration to be clear.

Treatment-Related Reasons to Object to the APA PTSD Guidelines

1. Limiting treatment to only those methods that are supported by RCTs is not the consensus in the field. The limitation risks provision of treatment by therapists from all orientations who do not adhere exclusively to the Guideline. 
2. The exclusive endorsement of RCT-supported treatments deprives patients of care from which they are benefiting.
3. The threat of deprivation of care is not to be taken lightly. Illinois BC/BS has already adopted these PTSD guidelines as a standard of medical necessity. The  , Guidelines give them a tool to refuse reimbursement for treatment
4. APA was aware of this risk and intended to address it by accompanying the treatment guideline with a professional practice guideline.  This assumes that users of the guideline will read both documents carefully and thoughtfully and will act based on such a thoughtful and honest analysis.  This is not a realistic assumption in the world of treatment. A recent CNN report indicated that a past Aetna Medical Director , "admitted under oath he never looked [emphasis added] at patients' records when deciding whether to approve or deny care” (para.1) https://www.cnn.com/2018/02/11/health/aetna-california-investigation/index.html.

Forensic-Related Reasons to Object to the APA PTSD Guidelines

1. This is also not a realistic assumption in forensic contexts. 
2. We are very concerned that if you are using any other treatment than those included in APA's PTSD Guidelines and someone wants to file an ethical charge, a licensing board complaint, and/or sue you for malpractice, they have a strong weapon in stating that APA’s PTSD Guideline only endorses a type of practice you were not using. Attorneys, disgruntled litigants, insurance companies, angry patients and others could easily assert that the Guidelines are the authoritative source, especially for psychologists, justifying theirmisuse despite APA’s disclaimers to support adverse administrative, legal, and ethical actions against responsible clinicians.

Scientifically-Related Reasons to Object to the APA PTSD Guidelines

1. Some commentators asserted the use of RCT’s as the scientific “gold standard.”
2. There is no dispute that RCTs have scientific merit.  They are a derivative of the experimental method, which depends on the isolation of variables.  The isolation of variables allows scientific experiments to infer causality.  That is their strength.
3. However, the limitations of experiments, and their derivative, RCTs, must also be recognized. Several people have commented on issues related to the limitations of RCTs in general and of APA’s RCT selection criteria specifically on various listserves and other forums.  It is beyond the scope of this email to recapitulate all those well-reasoned analyses.  The few discussed here have not been discussed with these specifics elsewhere.

1. PTSD is a disorder that can rarely be isolated from other disorders.  Co-morbidities are the rule, ranging from  60% to 100% (Friel, White, & Hull, 2008; Young & Drogin, 2014; Galatzer-Levy, Nickerson, Litz, & Marmar, 2013).  In battered women, PTSD alone is rare (Follingstad, 2003). 
2.  Gerald Young, Editor-in-Chief of the journal Psychological Injury and Law, writing on the misuse of PTSD diagnoses in civil tort cases, computed that including co-morbid symptoms creates 1.39 quintillion ways to have PTSD with common comorbidities (Young, Lareau, & Pierre, 2014).
3. The RCTs that were the basis for the Guidelines deliberated excluded co-morbid disorders.  This is appropriate if the method is to be based on the strengths of the experimental method and achieve its goal of making causal statements (i.e., “this treatment causes these symptoms to be reduced”).
4. However, it is the weakness if the goal is to achieve ecological validity for the results, b/c, simply put, trauma victims do not usually suffer from PTSD symptoms alone.

4. The problems caused by the isolation of variables is not limited to co-morbidity.  It also occurs when disorders are removed from their social, racial/ethnic, cultural, economic, political, and other contexts.  Decontextualization also limits ecological validity.  
5. APA’s Multicultural Guidelines emphasize this strongly.  Therefore, APA’s promulgation of both the Multicultural and the PTSD Guidelines lacks theoretical consistency and conflicts with the scientific principle of parsimony.

These reasons indicate that the APA PTSD Guidelines overgeneralize the basis for their treatment recommendations.  If they were promulgated as guidelines for the treatment of PTSD in patients with no co-morbidities, they would be tied more closely to their research evidence.  If they were promulgated as guidelines for patients whose social/etc. contexts were not seriously confounding their symptoms and recovery, they would be tied more closely to their research evidence.  As it is, there are no such limitations on their applicability and the only proposal in the pipeline (a separate document) may be scientifically responsible but is simply too easy to ignore for those who are motivated to do so.

For those of you patient enough to read this, I thank you and hope it clarifies some of the issues.  Please forward this to any divisions or other groups that you think might be interested.