Selling Bad Therapy to Trauma Victims

Patients and therapists should ignore new guidelines for treating trauma.

The American Psychological Association (APA) recently updated its guidelines for treating posttraumatic stress disorder (PTSD).¹ Patients and therapists would be wise to ignore them.

The guidelines claim to reflect the best scientific evidence. In fact, they ignore all evidence except one kind of study: the randomized controlled trial (RCT).

RCTs randomly assign people to treatment or control groups. They can answer certain questions (e.g., is a medication more effective than a sugar pill?) and not others (e.g., how does the medication work? What causes the disease?). In the absence of careful scientific reasoning, RCTs can lead to foolish conclusions.

Here’s an example: Some people wrongly concluded that tooth flossing lacks scientific support after a review of RCTs found little evidence of benefit. But here’s the problem: flossing is beneficial in the long run, and the RCTs followed participants for only short periods. They found exactly what you would expect—pretty much nothing. Knowledge about tooth flossing comes from other sources, including more than a century of dentists’ observations and an understanding of its mechanism of action (how it works).

Most scientific advances don’t come from RCTs

The basic or hard sciences, like physics, chemistry, or astronomy, did not progress through RCTs. No astronomer ever conducted an RCT, yet astronomers predicted the time and path of the last solar eclipse to the millisecond.

But some people, primarily in the social sciences, would have us believe that RCTs are the “gold standard” of scientific knowledge, and everything else should be ignored.

This is nonsense, and you don’t need an advanced science degree to see why.

No RCT has ever shown that the sun causes sunburn, sex causes pregnancy, or lack of food causes starvation. We know these things because we can observe cause-and-effect relationships and we understand the mechanisms of action. Ultraviolet radiation damages skin cells. Sex allows sperm cells to fertilize egg cells. People die without nutrition. Flossing removes dental plaque, which harbors bacteria that attack teeth and gums.

Copernicus, Galileo, Darwin, Einstein, Niels Bohr, Marie Curie, Stephen Hawking. What do they have in common? They never conducted an RCT.

Wrong questions, wrong answers

What does tooth flossing have to do with the trauma treatment guidelines? Everything. They are based on the same mistake.

Psychotherapy takes time. It follows a dose-response curve. It takes more than 20 sessions, or about six months of weekly therapy, before 50 percent of patients show meaningful improvement. It takes more than 40 sessions for 75 percent of patients to improve.² These findings, based on data from more than 10,000 therapy cases, align with what therapists report about successful psychotherapy,³ and with patients’ experiences.⁴^,⁵

The RCTs behind the trauma treatment guidelines considered only therapies of 16 sessions or fewer. Most were eight sessions or fewer. In other words: the guidelines are based on treatments known to be inadequate.

It was a foregone conclusion that the guidelines would recommend only brief, standardized forms of CBT delivered by following instruction manuals. This kind of therapy is expedient to study with RCTs, so it’s the only kind considered. Other research strategies—such as studying people who actually get well and what helped them—would almost certainly lead to different conclusions.

More than a century of scientific research and clinical experience point to something else: therapies that take the time needed to build a relationship of trust and focus on what is emotionally meaningful to individual patients (vs. standardized interventions from instruction manuals). But because this knowledge does not come from RCTs, it was ignored.

The guidelines are by researchers for researchers; the needs of patients and therapists are secondary. The 181-page document is filled with dense description of research methods and statistics, including 114 pages of tables and forms. Treatments are “recommended” based on research design—not because patients get well.

Truth in advertising

“These guidelines offer the field a number of benefits,” according to APA. “For providers, they offer recommendations… that quickly summarize which treatments have been shown to work for hundreds or even thousands of patients… For families, they provide clear information on best treatments and what to expect of them.”⁶

Let’s fact-check this against one of the largest and best RCTs behind the guidelines. The study, funded by the U.S. Department of Veterans Affairs and the Department of Defense and published in the Journal of the American Medical Association,⁷ included 255 female veterans. Most had experienced sexual or physical assault.

Patients received a “recommended” form of CBT (Prolonged Exposure) or a control (placebo) therapy that was not intended to treat PTSD.

Here’s what the study found:

• Nearly 40 percent of patients who started CBT dropped out. They voted with their feet.

• 60 percent still had PTSD after treatment.

• 100 percent remained clinically depressed after treatment.

• At 6-month follow-up, the CBT group did not differ significantly from the control group.

• Nineteen serious adverse events—suicide attempts, psychiatric hospitalizations—occurred during the study.

The authors wrote that patients “may need more treatment than the relatively small number of sessions typically provided in a clinical trial.”

I did not choose this study because it is flawed. I chose it because it’s one of the best. In fact, two-thirds of patients who receive APA’s “recommended" treatments still have PTSD when treatment ends.⁸

“Clear information on best treatments and what to expect of them.” Really?

The original guideline authors repudiated the guidelines

In an unprecedented development, the chair of the original PTSD guideline development panel published a paper renouncing both the guidelines and the process that produced them.⁹ The paper, co-authored with another panel member, described being strong-armed by APA leadership to produce guidelines based solely on RCTs—disregarding both accumulated clinical knowledge and a vast body of evidence.

They wrote:

“It soon became apparent that this guideline was being developed in a relative vacuum, one in which the long history of psychotherapy outcome research was treated as if nonexistent... the guideline group was provided only a highly restricted body of research on which to draw, with exclusionary criteria that removed the bulk of the available evidence-based studies of trauma treatments.”

They also reported learning, after the fact, that APA had appointed health insurance executives from United Behavioral Health to key committees, which

“left us uncertain as to the degree to which the PTSD guidelines were in fact kept safe from external influences and pressures.”

First, do no harm

Health insurers discriminate against psychotherapy. Although congress has passed laws mandating parity between mental and physical health coverage, insurers routinely circumvent them.

It’s bad enough that most Americans lack access to adequate care. It’s worse to be misled into believing that inadequate therapy is the “best” therapy.

The APA’s ethics code begins, “Psychologists strive to benefit those with whom they work and take care to do no harm.” APA has an honorable history of fighting for access to quality care.

Under the guise of science, APA has handed another trump card to the worst actors in the health insurance industry.

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More essays, interviews, clips, and reflections: linktr.ee/jonathanshedler

1. American Psychological Association (2025). APA Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults. https://www.apa.org/about/policy/guideline-ptsd-in-adults.pdf

2. Lambert, M.J., Hansen, N.B., Finch, A.E. (2001). Patient-Focused Research: Using Patient Outcome Data to Enhance Treatment Effects. Journal of Consulting and Clinical Psychology, 69, 1590-172.

3. Morrison, K.H., Bradley, R., Westen, D. (2003). The external validity of controlled clinical trials of psychotherapy for depression and anxiety: A naturalistic study. Psychology and Psychotherapy: Theory, Research and Practice, 76, 109-132.

4. Mental Health: Does Therapy Help (1995, November). Consumer Reports, 734-739.

5. Seligman, M.E.P. (1995). The Effectiveness of Psychotherapy: The Consumer Reports Study. American Psychologist, 50, 12, 965–974.

6. Deangelis, T. (2017, November). PTSD guideline ready for use. Monitor on Psychology, 48(10), 26-27.

7. Schnurr, P.P., Friedman, M.J., Engel, C.C., et al. (2007). Cognitive Behavioral Therapy for Posttraumatic Stress Disorder in Women: A Randomized Controlled Trial. Journal of the American Medical Association, 297, 820-830.

8. Steenkamp, M.M., Litz, B.T., Hoge, C.W., Martmar, C.R. (2015). Psychotherapy for military related PTSD: a review of randomized clinical trials. Journal of the American Medical Association, 314, 489-500

9. Courtois, C.A. & Brown, L.S. (2019). Guideline Orthodoxy and Resulting Limitations of the American Psychological Association’s Clinical Practice Guideline for the Treatment of PTSD in Adults. Psychotherapy, 5, 3, 329-339.