Source: Emerson Lima on Unsplash
At the end of each year, I pick research studies on trauma and posttraumatic stress disorder (PTSD) with the aims to help consumers evaluate the quality of research and to understand what issues are important at the moment. The best way to do this I think is to highlight both the best and the worst of research.
The best studies focus on what I believe are the only two questions in medical research worth studying: (1) prediction of who is going to develop problems so that the problems may be prevented, and (2) prediction of treatment response in controlled settings. Both types involve prediction of future behavior and are narrowly focused on actually helping people.
The worst studies are peppered with bias that were conducted to confirm what researchers already believed. To be fair, it is difficult to conduct good psychological research. It is impossible to conduct a perfect study that controls for every possible methodological and personal bias.
The following studies are mostly good studies that either provide important new knowledge or help to expose some of the bad practices in the trauma field.
(1) Some PTD in very young children may be preventable
Randomized psychotherapy trials for trauma are difficult to conduct and, when done well, deserve recognition. A study led by De Young and Landolt is even more noteworthy for being the first attempt to intervene early to prevent PTSD in very young children (Haag et al., 2020). A two-session CBT protocol showed greater improvement compared to the control group after three months, but not after six months. The results were mixed but there was definitely a subgroup that benefited greatly from the intervention. (Disclosure: I consulted with the authors but had nothing to do with the conduct or reporting of the study).
(2) The explosion of poor-quality research during COVID-19 pandemic
I could just ask you to read my last five blogs. Most of the psychological research during the pandemic has been poor-quality, rushed into print with little peer review, and probably massively overestimates the mental health impact. Criticism from other experts has been rare, unfortunately, and one good article stands out. Van Overmeire, a Belgian sociologist, critiqued a study that had supposedly found high rates of PTSD in the general population of Ireland. The critique noted that the Ireland study did not properly assess life-threatening events and likely allowed respondents to answer about many non-life-threatening events, which is known to lead to overestimates of PTSD (Van Overmeire, 2020).
(3) Please stop blaming mothers. Please.
Historically, mothers have been wrongly blamed for autism, schizophrenia, and other problems with their children. As each one is debunked, the blame-the-mother game just moves to another target, and PTSD is a favorite target now. A study used a new audio recording technology to test this theory again. Following serious injury and hospitalization, children returned home wearing a device that recorded audio for 30 seconds every five minutes. Using a similar method, researchers had already shown in a 2017 paper that the amount and tone of parental talking had little to nothing to do with children’s emotional recovery. In this study, parental talking with children also had no association with parents’ stress level and self-efficacy (Mangelsdorf et al., 2019).
(4) Clinicians have much difficulty adopting evidence-based psychotherapy (again)
It is old news that effective evidence-based psychotherapies (EBP) exist but few clinicians use them. An excellent group of researchers led by Jankowski and Barnett tried to implement two EBPs for trauma-exposed youth in community clinics in New Hampshire. Out of 292 clinicians who agreed to participate, only 70 (24%) completed training. Youths who were treated by the fully-trained clinicians markedly improved (Barnett et al., 2020). This study shows that clinician adoption is the bottleneck.
(5) Voluntary implementation of EBPs does not work
I hate to use word space to make a point that is redundant with #4, but I cannot help myself. Researchers at a Veterans Administration focused on understanding early responders (improved with eight sessions or less), later responders (improved with nine sessions or more), and nonresponders (Sripada et al., 2020). What they did not mention was that the entire sample may be skewed by a selection bias. In 2018, this group of researchers had published a study from the same dataset (Sripada et al., 2018). In that study, they found that only 8% of patients who were in psychotherapy with the primary diagnosis of PTSD were being offered an EBP by their clinicians. And this was in the VA system, where EBP usage is mandated. In other words, in the VA system, were EBP usage for PTSD is mandated, clinicians were opting to offer an EBP only 8% of the time. Many of those patients who were not offered an EBP may have comorbid conditions that contraindicate treatment for PTSD, but it is unlikely that could apply to 92% of them. Bottom line: voluntary implementation of EBPs is slow and clinicians are the bottleneck.
(6) Toxic stress is more like hypoxic mess: Can this theory please die?
Toxic stress, the theory that trauma and stress can permanently alter neurons and circuits, is widely believed and is increasingly being weaponized by ideologues to drive social engineering. My review paper showed that when better quality research is examined, there is not only little research to support it and much research against it, but it has become popular due to a fatal misunderstanding of cross-sectional research and a highly coordinated group of activists (Scheeringa, 2020).
(7) Somebody call 60 Minutes: Trauma-informed care does not work.
During the past ten years, trauma-informed care (TIC) has been hyped with almost cult-like mania in the United States as the answer for every social disparity. For example, Oprah Winfrey did a passionate promotion of TIC on 60 Minutes (see my blog from 3/27/2018). Trauma and stress in childhood supposedly rewires the brain (i.e., toxic stress) and causes the cycle of poverty, the cycle of joblessness, homelessness, and incarceration (see my blogs 9/17/2017 and 9/10/2018). The research team of Jankowski and Barnett make the list a second time for their attempt to implement trauma-informed care in the New Hampshire child welfare system with a randomized design. After training child welfare workers for three months on a variety of trauma-informed competencies, there were no significant changes in their practices. The researchers conclude, “In our assessment, the fact that we did not find a more significant effect from this multifaceted, and fairly costly, intervention raises some questions about the effectiveness of comprehensive TIC interventions” (Jankowski et al., 2019).