Controversial Exposure Therapy for PTSD Challenged


Research published in the May 2015 issue of The American Journal of Psychiatry questions the use of exposure therapy, the “gold standard” treatment for patients with PTSD.  Exposure therapy attempts to lessen the power of memories, thoughts, and feelings related to the trauma through the repeated discussion of the trauma-related situations with a therapist.  While prior studies have reported that it is efficacious,  exposure therapy has also been called the “cruelest cure” and criticized for inducing suffering in victims of trauma.

A new study, led by Dr. John Markowitz of Columbia University, found that a gentler form of psychotherapy, where patients “focus on current interpersonal encounters rather than past trauma,” could be a good alternative to exposure therapy.  The study randomly assigned unmedicated patients with PTSD to three different therapies for a 14 week period.  The three treatment groups included exposure therapy, interpersonal therapy, and relaxation therapy.

The highest response rate was found in the interpersonal group (63%), compared to 47% in exposure therapy, and 38% for relaxation therapy.  Both interpersonal therapy and exposure therapy produced superior improvements in quality of life and social functioning than relaxation therapy.

The drop-out rate was also higher in the prolonged exposure group than in the interpersonal cohort. In particular, patients with comorbid major depression dropped out from “prolonged exposure” nine times more than non-depressed  patients treated with exposure therapy.

The researchers concluded: “Contradicting a widespread clinical belief, PTSD treatment may not require cognitive behavioral exposure to trauma reminders. Moreover, as differential therapeutics, patients with comorbid major depression may fare better in Interpersonal Psychotherapy than Prolonged Exposure.”

Markowitz, J. C., Petkova, E., Neria, Y., Van Meter, P. E., Zhao, Y., Hembree, E., … & Marshall, R. D. (2015). Is exposure necessary? A randomized clinical trial of interpersonal psychotherapy for PTSD. American Journal of Psychiatry172(5), 430-440. (Full Text)



    • Exactly. People have a tendency to read these kind of study without questioning it. What is meant by psychotherapy? It takes several years of therapy for a person to heal from trauma or PTSD. This study was done over a period of between 3 and 4 months. That is a small window into the trauma stabilization, processing and recovery periods. Successful trauma treatment never relies on one specific treatment modality. “Exposure therapy” can be useful if done in small increments and when done at an appropriate time during the course of treatment.

      Dr. John Markowitz loses credibility with me when he states that focusing on “current interpersonal encounters rather than past trauma,” could be a good alternative to exposure therapy. PTSD cannot be healed without some effort to make sense of past experiences, this can be accomplished through a number of different means (EMDR included), however, it is not accomplished through “talk therapy”. Dr. van der Kolk makes this point in his book, “The Body Keeps the Score”.

      So, while I can see that in this short term study that it is possible that interpersonal therapy was more effective than exposure therapy, it says nothing about the long term prognosis for these individuals with PTSD.

      The comment regarding the lack of efficacy among those with major depression was also telling because the effectiveness of exposure therapy is connected to one’s ability to stay within a window of tolerance. A depressed patient is not typically going to be able to engage in this type of work because they are not sufficiently ‘aroused’, they are ‘hypoaroused’. They tend to be shut down, in other words, which becomes a challenge for the therapist treating them.

      Pat Odgen PhD., a trauma expert talks about these challenges and the window of tolerance, here:

      Depressed patients may ‘respond’ more positively to interpersonal therapy (they may be more active participants in treatment) however, it does not mean that their issues with PTSD or trauma will effectively be resolved in this manner. This is why these short term reserach studies are of limited value since they do not add to the understanding of how to treat trauma appropriately. Rather, the study serves to discredit exposure therapy as an invalid treatment modality, when in fact, it’s only one of many types of interventions that professional trauma therapists use in their work.

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  1. The first rule in treating anyone who has been traumatized is don’t re-traumatize the person! This should be obvious and should not need research to support this approach. This first rule leads to a second rule: Establish a trusting positive working relationship.
    Some people may feel a need to talk about the traumatic events quickly. Other people want first to feel safe with the person that they are talking to. As bpdtransformation points out therapy can take years, partially because it can take years to establish a trusting relationship when someone has been badly traumatized in life.
    Safe space is crucial in any therapy, but is not achieved just by being nice to someone for a few weeks. One always has to show utmost respect for the person’s real life experience and their time frame. This is one reason why it is so hard to do research on trauma, as unless one takes an individualized approach, results will always be mediocre at best.

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    • Concerning long-term psychotherapy, here is a recent metaanalysis out tracking the results of 2-3 year length psychotherapy that are encouraging:

      Knekt’s Helsinki Psychotherapy Study – Randomized 3 year long-term vs. 6 month short-term psychotherapy study:

      The intuitive, expectable outcome was present here : more human-to-human help usually is better, up to a point.

      They should do a 3-5 year study of intensive psychotherapy for psychosis versus only medication for psychosis. If done well, it could produce some shocking results, similar to Open Dialogue.

      Here’s an example of what it could do… Mehl-Madrona’s study of 51 psychotic clients treated with intensive psychotherapy and very limited medication, and followed up on average about 5 years:

      The results are on page 70 of the file.

      If this type of study were done on a larger scale, it could be very dangerous indeed to drug companies.

      Norman, maybe you should write some essays for the site. You are a good writer.

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      • Thanks!

        I actually have submitted a couple of articles with more to come. You can also read some posts at my blog site: or at my website I’ve been impressed with your comments too. I would be interested in communicating with you as it seems that your experience coincides with my interests. I’ve spent most of my career devoted to trying to help people who fit the diagnosis of “borderline personality” to live happy and healthy lives. I have no interest in simplistic techniques to just reduce some symptoms. All people, especially those who have been deeply traumatized, deserve respect and support, as they struggle to regain a sense of themselves. The psychiatric industry tends to just want these people to go away and stop showing up in the emergency rooms without offering any hope for a real future. Transformation is possible but it takes dedication on the part of the therapist and the individual.
        In my whole life experience the one thing that has impressed me the most is how some deeply traumatized individuals can hold onto empathy and hope despite their experience of how horrific some people can be. We can all learn from the values some abused individuals hold onto despite their experiences that should leave them giving up on the human race. These people leave me in awe and with deep respect.

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    • Good point about the importance of establishing a trusting relationship with one’s therapist, especially for those of us with a trauma history. It has been empirically established that the relationship with one’s therapist is the greatest factor in determining the perceived success of treatment by both the patient’s and the therapist’s perspective. This is more important than any particular treatment modaility that is used in the service of treating trauma.

      While I always like the idea of someone being ‘nice to me for a few weeks’ (over not having anyone at all to listen to my problems!) that’s not, unfortunately, how the trauma therapy process unfolds. Dr. Hoffman is right to say that ‘trauma therapy’ can never be a exact science. It is better thought as a labor of love and an art form. It requires a special person to be able to be present to someone’s pain. It also requires creativity to be able to address the trauma in a way that feels honoring to the patient as well as using modalities that are suitable in a particular case. Trauma treatment requires an individualized treatment plan which is part of the ongoing assessment that a skilled trauma therapists does during the course of their work with a client.

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  2. I am sure that if a particular therapy; such as exposure therapy was determined to be the “cruelest therapy” it would be then decided to be the therapy of choice and the first line therapy. Please forgive me my tragic cynicism as a “psychiatric survivor.”

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  3. I’m not familiar with exposure therapy, so I won’t comment on it. What I am familiar with is negligently being prescribed SSRIs and benzos for 20 years for anxiety and depression, and worse yet, for what I now believe was in fact PTSD.

    I’m not afflicted by the more typical PTSD associated by being involved in, or witnessing, a single horrific act or catastrophe. Mine is the less recognized PTSD caused by cumulative effects of years of childhood emotional abuse. (I suppose this is more akin to a shell-shocked soldier who gradually becomes a nervous wreck after repeatedly hearing explosions, and then upon returning home, feels threatened, overwhelmed, and unable to cope with everyday life.)

    Furthermore, the mental and physical consequences of 20 years on SSRIs and benzos, whether for anxiety, depression, or PTSD, or whatever, have been devastating.

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    • The “TS” – the “Traumatic Stress” of “PTSD” can be a single biggie, like a murder attempt, serious car crash, or WAR, of course, or even the chronic trauma of child abuse. Whether verbal, emotional, psychological, sexual, whatever, abuse is abuse is abuse…. Different types of abuse will produce different patterns of so-called “symptoms”, in different persons.
      “Repeat After Me”, and “For Your Own Good”, are 2 book titles that I recommend VERY STRONGLY to you. (Sorry I can’t remember the author’s name)
      They greatly helped me understand, and recover from my own childhood trauma.
      Also, even non-alcoholics almost always benefit from a careful study and practice of
      AA’s 12 Steps. It’s a program of recovery that YOU can do yourself, alcoholic or not.
      And, yes, you CAN work on your SSRI & benzo “issues”, using AA principles….
      These things helped me, and I’m simply sharing them with you….

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  4. This makes me think of a funny story from Andrew Solomon’s TED talk where he is talking to a Rwandan health care worker.

    Rwandan Guy: We’ve had a lot of trouble with western mental health workers. Especially the ones who came right after the genocide.
    Andrew Solomon: What kind of trouble did you have?
    Rwandan Guy: They would do this bizarre thing. They wouldn’t take people out in the sunshine where you would feel better. They didn’t include drumming or music to get people’s blood going. They didn’t involve the whole community. They didn’t externalize the depression as and invasive spirit. Instead, what they did, was they took people, one at a time, into dingy little rooms and had them talk for an hour about bad things that had happened to them!? We had to ask them to leave the country.

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  5. Is it too soon to expect any studies out there on PTSD FROM psych abuse? Surely, there are thousands who are suffering this, yet the trauma centers refuse to list this trauma among the many possibilities (though they list all the ones that are far more unlikely, such as earthquakes, terrorist attacks, etc.). Far more people are abused in hospitals and in therapy than ever see serious scary stuff from an earthquake. I cannot imagine walking into a therapist’s office without getting scared. In fact, any time I have to sit in a waiting room (such as waiting at the electric company to do paperwork) I get the shivers remembering shrinkage. I still flinch at the sight of a hospital and I get scared when I see an ambulance. Thankfully, the sight and sound of ambulances and rushing police is a rarity here in Uruguay. If ever I see a shrink, even in a You-Tube, and see their beards, their impeccable suits, their tans (straight off the golf course) and think about their smug attitudes, I feel my blood boil. How can such a thing possibly be resolved? All I can do is to try to hide away from shrinks and hope I never see one again, nor have to hear the sound of their voices nor bow down to their ideas. I don’t think all shrinks have bad intentions, but if you have been traumatized, it’s hard to not feel terrified. Would you expect someone who has been bitten by a dog to be able to instantly say, “Not all dogs are bad” and run out and befriend the nice ones? Not likely, until they somehow get over the fear. I know generalizing is illogical, but a person is only protecting him/herself.

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