Cognitive behavioral therapy is a terrible way to treat trauma. And it’s government approved.

IMG_0525_editedblack-1_edited-1The Department of Veterans Affairs may today deliver the worst trauma treatment known to man or woman.

The diagnosis of PTSD is an outgrowth of the protests over the Vietnam War. Distraught and disillusioned Vietnam veterans, together with psychiatrists such as Robert Jay Lifton and Chaim Shatan, developed the “rap groups” that provided psychological support in a community of other vets who had undergone similar experiences. Rap groups worked because they provided a place to share common experiences, including terror and remorse. Rap groups provided community and social support.

The effectiveness of rap groups eventually convinced the American Psychiatric Association to include Post Traumatic Stress Disorder in the third edition of its Diagnostic and Statistical Manual, though this is a long and convoluted story (see http://traumatheory.com/whats-going-on-with-dsm-5/ for more details). For some time, rap groups were employed by the VA, often with reluctance, for their members were not always easily managed (Sonnenberg, Blank, Talbott).

No more. David Morris’ recent account of his experience with cognitive behavioral therapy at the San Diego VA tells of a sign on the wall of a waiting room for a small group of vets who were about to enter therapy (p. 195).

PLEASE REFRAIN FROM TELLING WAR STORIES. YOUR STORY COULD BE A “TRIGGER” FOR SOMEONE ELSE.

If the traumatized cannot talk with each other, but only through a therapist, even in a group, then therapy is no longer about creating a community of support for those who suffer. It’s about isolating those who suffer from each other, so they can be processed individually, their trauma chopped into bits.

I am not a veteran; I have not been subjected to the VA’s trauma treatments. My opinion is based on reading the publications of the Veterans Affairs National Center for PTSD, several good books, including The Evil Hours, by Morris, and my own understanding of trauma, which I have laid out in 30 posts this year.

First line treatments

The VA recognizes as “first line treatments” only versions of what it calls cognitive behavioral therapy (CBT). First line treatments means the only treatments that have been scientifically validated. The terminology is a little confusing, so stick with me. Under CBT, the VA includes highly focused small group therapy, designed to correct “distorted cognitions, which are derived from . . . dysfunctional beliefs.” (Clark and Beck, pp. 116-118)

CBT also includes prolonged exposure therapy, sometimes called flooding, in which memories of a traumatic event are rehearsed (retold) again and again. The idea is that the intense initial reactions of panic will be “extinguished” over time as the mind and body become used to being overwhelmed.  Not everyone considers flooding a version of CBT, but the VA does.

As a less effective but still “first line” treatment, the VA includes eye movement desensitization and reprocessing (EMDR). EMDR is a version of exposure therapy in which the traumatic event is rehearsed while the eyes move back and forth, or the therapist taps your hand. No one quite seems to know how EMDR works. The eye movements may mimic REM sleep, allowing traumatic memories to be reprocessed, but there is no quality scientific research supporting this hypothesis, and it wouldn’t explain why hand tapping seems to work as well.

Why these are bad treatments

These are bad treatments because they assume that PTSD stems from a particular dramatic and traumatic incident, such as an explosion, rape, car accident, and the like. Trauma that develops over time, not just chronic PTSD, but the trauma of a long deployment, or a long illness, doesn’t fit. Trauma is reduced to an event. This represents

a fundamental misapprehension of the nature of trauma as I experienced it in Iraq, trauma that to my way of thinking was far more about the cumulative effect of living under fear of death for months and then coming home and realizing that no one cared in the slightest about it than it was about a single close call with an IED. (Morris, p. 192)

Yet, it is exclusively with Morris’ close call with the IED that his treatments focused on. They had to, for they are not designed for talking, but for programmed interaction.

Flooding is torture

Flooding, or prolonged exposure therapy, has taken the worst rap, as it essentially demands that the trauma victim reexperience his trauma over and over again. For this to work, it has to focus on a traumatic incident, not trauma as a process extended over time. Some therapists and researchers consider it dangerous. It’s a reasonable conclusion, considering that flooding essentially simulates the original trauma. Morris asks

What is it about post-traumatic stress that makes such sadistic methods seem reasonable? What is it about post-traumatic stress that so confounds the clinical mind that it resorts to methods that are virtually indistinguishable from torture? Could it be that there is some daemonic repetition-compulsion at work here? . . . A writer friend . . . mentioned offhand that PE seemed in some ways to resemble an exorcism. (Morris, p. 193)

Such a conclusion only makes sense if we adopt the following assumption. The traumatized person is someone who has seen and knows a part of the world that the rest of us cannot bear to know. “Trauma is the savagery of the universe made manifest within us.” If this is so, then flooding (prolonged exposure) would be not so much a way of driving the demons out as it would be tormenting the messenger until he or she is exhausted, or worse. This is a harsh conclusion, but exposing the traumatized person to his or her trauma over and over again is harsh treatment.

CPT is discipline

While flooding seems the most damaging, one should not underestimate the damage of what is usually known as cognitive behavioral therapy, what the VA calls cognitive processing therapy (CPT). In a small group, participants are asked to evaluate whether their extreme beliefs, from which their trauma supposedly flows (contrary to much evidence that trauma is not a cognitive experience), are really rational or normal. Morris gives this example.

When, in one of my first “A-B-C” sheets, I wrote that “A. The government lies. B. People in power are liars and their lies killed friends of mine. C. I feel sick and helpless about it,” I was urged . . . innocently, even sweetly, by Chloe [his therapist] to investigate whether my “B” belief was, in fact, “100 percent realistic.” (Morris, p. 203)

If PE resembles torture, then CBT resembles what Michel Foucault calls discipline, in which experts define what counts as normal, exerting pressure on the rest of us to conform. Discipline is the modern, or sophisticated, version of punishment.

Treatment that can be practiced from a handbook

The treatment of PTSD has become “manualized,” something that therapists with minimal training and experience can learn and practice from a handbook. Once again, this assumes trauma is a discrete event that can be managed by a psychological technique, rather than an assault on all that one has ever presumed to be right, good, just, and fair. Trauma destroys worldviews, above all the view that the world is basically a good, or at least decent, place to live.

When trauma professionals control treatment

Most people have heard about the long waiting lines for treatment at VA hospitals, primarily the result of the wars in Iraq and Afghanistan. The need to shorten waiting times has led to a preference for treatments for PTSD that can be completed relatively quickly, often in a dozen sessions, by therapists with minimal training.

But, there is a larger issue at stake: what happens when professionals get their hands on a treatment that was originated by veterans? Measurement of results counts more than quality, and what can be measured becomes what it real. Worldviews, and their destruction, can’t be measured, though perhaps their “side-effects” can. One study showed that even when CBT works to reduce anxiety, it has little effect on “the negative emotions,” including shame, guilt, and anger (Pitman et al.).

The originators of the rap groups that led to the diagnosis of PTSD saw the disorder as an indictment of a society that would send its young men to fight a pointless war. Today PTSD is the subject of professional discipline. The result is that a concept that helped many to make sense of their suffering by seeing it as a reaction to a brutal and senseless world, a concept that helped bring veterans together, has become a technical process to be applied to symptoms one veteran at a time.

References

David Clark and Aaron Beck, Cognitive Therapy of Anxiety Disorders: Science and Practice. New York: Guilford Press, 2011.

Michel Foucault, Discipline and Punish: The Birth of the Prison. New York: Vintage Books, 1995.

David Morris, The Evil Hours: A Biography of Post-Traumatic Stress Disorder. New York: Houghton Mifflin Harcourt, 2015.

Roger Pitman, Bruce Altman, Even Greenwald, Ronald Longpre, M. L. Macklin, R. E. Poiré, and G. S. Steketee, “Psychiatric complications during flooding therapy for posttraumatic stress disorder,” Journal of Clinical Psychiatry, 52 (1), 1991, 17-20.

Stephen Sonnenberg, Arthur S. Blank, and John Talbott, eds., The Trauma of War: Stress and Recovery in Vietnam Vets, pp. 167-191. Washington, D. C.: American Psychiatric Press, 1985.

United States Department of Veterans Affairs, National Center for PTSD. “Treatment of PTSD.” http://www.ptsd.va.gov/public/treatment/therapy-med/treatment-ptsd.asp

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Comments (30)

  1. At LAST! AFTER WEEKS OF SCOURING THE INTERNET ON THIS SELF THERAPY PROJECT, SOMEONE WITH A FUNCTIONING BRAIN TALKING ABOUT PTSD—OTHER THAN THOSE HE MENTIONED, OF COURSE. MY ATTACKER WAS A VA SHRINK AND HE ATTACKED ME IN A ROOM ADJACENT TO THE WAITING ROOM IN A VA CLINIC WHERE HE CORNERED ME, CONFINED ME AND TREATED ME LIKE A CRIMINAL SUSPECT GETTING THE “WORK OVER” BY A TEAM FROM NYPD SPECIAL VICTIMS UNIT!

    • calford@umd.edu

      Thanks for your reply Mark. I’ve received emails from others who have gone to the VA, and I’ve concluded, based on a very limited sample, that there is something about the VA bureaucracy that makes many good doctors and therapists bad, or at least unfeeling. Which is about the same as bad. Fred

    • In one of the replies to this article someone bought up a excellent point. Psychoanalysis especially traditionally speaking is not very effective at all on PTSD. I agree it wouldn’t take months but years or never alleviate some of your awful symptoms. It doesn’t matter if you were no potty trained on time or your got some of Erickson stages out of sequence. The only thing that matters is to relieve some of your anguish. It not important the why. Cognitive therapy is much better at this because it teaches you how to change the way you react to stressors . We as humans always have stress good and bad. It’s called life. A Therapist once told me(of course this is not a novel Saying) She reminded me that Life is, what happens when you are making plans. In other words It’s not the weeding, the Graduation or the Trophy! No it want you did in the months and years leading up to your accomplishments. Live in the moment. Don’t wish for next next year. Easier said then done . Cognitive therapy worked for me but a big But I couldn’t have concentrated on the therapy with augmenting it without access to SSRI’s and with and only with benzodiazepines. Point being the VA can lump every one together. It’s like prejudice, all certain race people are alike. Well that’s preposterous.

      • calford@umd.edu

        Dear Jerome, In the end trauma theory isn’t important.  Important is that you, and others (including me) feel better.  If CBT and SSRI’s help you, then good.  I have a suspicion that WHO does the CBT matters.  Manualized (from a manual) or not, it’s still a relationship.  Many will know more about this than I do.  Fred

  2. Mark Clark, USNAVY HM!, now a retired pastor PCUSA

    Thanks for the reply. I’ve been heavily engaged in my own self therapy consisting of getting on line and raising hell with the assholes that think “Exposure Therapy” is a type of “Therapy.” As I made note of before, there’s a medieval painting of a place in that time period where “treatments” of that kind are illustrated. Id like to see that painting put in the VA clinics with a sign saying, “We don’t do this anymore”/ Then I’d like to see them live up to that promise.—FAT CHANCE! (The Illustrations of hot branding irons being applied to the genitals are particularly graphic as I recall.

    • Anonymous

      If trauma is torture, as I said in my most recent post, then so is exposure therapy. I don’t think the idea was to torture people, just to find something quick and easy. But the result is the same. Anyone with a good experience with exposure therapy out there? Fred

      • Ari

        Im going through it right now. I feel like im going crazy. I am going crazy. Cant sleep, eat, work, or leave my house. I just wanted to see if there were others experiencing this because i felt like my therapist was trying to normalize what im going through.

    • Kathleen Rivers

      I live in Virginia now and after Thyroid Storm in NC fall of 2016 I moved back to Virginia. Someone has employed churches to treat me without my consent! If it was consent it was cohurst! I am 51 and no mental history of anything. All of a sudden I ask for help and was followed to my daughters job wrote down plate. I wind up in a mental institution for almost a month, forced drugged and kept in a freezing room exposed to people all cut up and drug attics??? I was striped of civil rights, I don’t have a driving ticket the past 20 years? Come to find out it is a professor of sociology at ODU is the area of deviat behavior??? My beautiful son Lancaster died in 2012 and this sick Williamsburg Community is doing this??? For the first time in my life I don’t want to live anymore. They made it look like my oldest was raped the police never gave me a report, this is because zig have always told my children to be aware of strangers and my ex thought that was funny? I have been told everyone on different occasions are dying or sick, my oldest is a type 1 diabetic and now thyroid problems. I have been abused threw exposure therapy with death and people running in front of my car and
      Putting children on there shoulders to upset me. I have had my Facebook send explicit children suicide images and stories using my family members to me. I have had a military father with a baby tell me it is ok with GOD to kill myself??? Please help me. My name is Kathleen Rivers

      • calford@umd.edu

        Dear Kathleen, I’m so sorry that life is so difficult for you. In my experience a few people care, most don’t bother, and a few are actively hostile. It sounds to me like you are an interesting, thoughtful person. Please don’t harm yourself. You make this world a better place. Fred

  3. Emma

    Using CBT to “heal” trauma, as for much human suffering, is misguided, at best. Unfortunately, American mental health professionals are indoctrinated into this so-called “evidence-based therapy” as a matter of course in their careers, and accept it uncritically (and if they don’t, they are forced to pretend that they do).

    • MM

      I agree!!!
      When popularity hits, no one really thinks.
      I ve had PTSD.

      I do not believe clinicians can fathom the intensity of PTSD. The hyper arousal, nightmares, all . They cannot to not even validate the experience . I attended a class of CBT.
      I thought the teacher a sadistic witch. This person came to class and she just found out she never walk again. Teacher or therapist or whatever she was did not even validate her.
      She actually yelled at her to not bring her traumas to class. I got up and walked out.

      I did not find anything in the class that help PTSD. I had once lived the nightmare for a couple of years.

      Validation goes a long way.

  4. John B.

    There is a great article from Psychology Today’s November 2017 issue written by Jonathan Shedler, PhD which discusses this very issue. In the article, Shedler makes the following points:
    1.)Cognitive Behavioral Therapy is usually brief and manualized (8-12 sessions), but helpful psychotherapy takes time: at least 20 sessions for 50% of clients to show meaningful improvement (or 6 months of therapy), and at least 40 sessions for 75% of clients to show meaningful improvement (or one year of therapy).
    2.)Nearly 40% of those who started CBT dropped out of treatment. They voted with their feet about its usefulness.
    3.)60% of the patients still had PTSD when the study ended.
    4.)All patients were clinically depressed at the start of treatment and remained clinically depressed after treatment.
    5.)At six-month follow-up, patients who received CBT were no better than those who received the control treatment.
    6.)Nineteen serious “adverse events” occurred over the course of the study, including suicide attempts and psychiatric hospitalizations.
    7.)The authors soberly noted that the patients “may need more treatment than the relatively small number of sessions typically provided in a clinical trial.”

    And, Shedler bases his assertions on outcomes published in a Department of Defense/Department of Veterans Affairs study.

    • Marcia

      Hello all,
      Would it be possible to suggest what is the alternative to CBT for trauma treatment? Perhaps classical psychoanalysis? I am a bit confused, as I searched for a trauma specialist to swirl with me and she is insisting that I should not go over and over the trauma again, but engage an activities that make me feel better. I can understand the benefits of looking to another direction, but I definitely could spend many more sessions talking about the past…

      • Marcia

        Not swirl, treat

      • Anonymous

        Dear Marcia, I’m not sure how well classical psychoanalysis would work, but if you need to talk about it, and most do, then find a therapist who likes to talk and is fairly smart. Also, live your life as fully as you can. These are not really alternatives. You can do both. Fred

        • Anonymous

          I would try sensorymotor psychotherapy or somatic psychotherapy to unlock the trauma trapped in your body not just your mind

          • calford@umd.edu

            I’m not sure what’s best, probably a combination of talk and something that gets at the trauma locked inside the body-brain. Sensory-motor or somatic psychotherapy sounds like a good place to start, but talking is still important. Thanks for the comment. Fred

    • Anonymous

      Wow! Quite a story. Fred

  5. Anonymous

    Dear John, I believe (though cannot prove it) that most practitioners of CBT know that CBT doesn’t work, but it is so quick and easy, and can be done by the semi-skilled, that no one wants to say it aloud. Sometimes CBT is torture; rarely, I think, does it work. Thanks for your thoughtful comment.

    • Yes the only thing that has worked for my PTSD is avoidance of the thing itself & stupid therapists
      Only thing that has worked is quick acting antianxiety drugs

      • calford@umd.edu

        Dear Yvonne, there are some good trauma therapists around, but the trouble is (as you have found out) you often have to go through so many bad or mediocre ones to find a good one. Might be worth it to keep trying. Glad the meds help. Fred

  6. Gary Freedman

    I was in CBT-based trauma therapy for nine months, and I found it to be useless. I wrote a book about my experiences. The text of the book is at the link below:

    https://dailstrug.files.wordpress.com/2018/09/psychotherapy-reflections-march-12-2019-final-copy.pdf

    • C. Fred Alford

      Gary, I’m not surprised you found CBT therapy useless. It’s too bad. I’m still not sure if those who promote it are utterly cynical (it saves time and money), or actually believe it helps. It depends. Probably both. Thanks for sending along this link to your book. Fred

      • Gary Freedman

        My thinking is psychoanalytically oriented. I purchased a copy of your book Group Psychology and Political Theory and was gratified by your psychoanalytic references.

        The book I posted has a lot of material that compares my therapist to cult leaders; I also compare my experiences in a dysfunctional group in the workplace (I was the independent-minded scapegoat) with my experiences with my therapist. It was as if the therapist was a cult leader who was put off by the fact that I did not regress to a state of worshipful adoration (like a good cult follower).

      • Gary Freedman

        You raise an issue that I have thought about myself: “I’m still not sure if those who promote it are utterly cynical (it saves time and money), or actually believe it helps.”

        I am reminded of Grunberger’s observations about one type of superego disturbance. Grunberger talks about a certain personality type that is characterized by a lack of ego homogeneity, a split ego that encompasses a distinct sadistic trend as well as a capacity simultaneously to be a good member of the community, an affectionate spouse, and an exemplary parent. The specific regression also affects his superego, which is an incomplete construction based on different superego formations, each corresponding to a different and overlapping phase in its development. The principal part is played by a precociously formed superego which is based not on the
        116introjection of complete objects but on their educative function. It pertains to a training role, which is represented in the unconscious by the introjection of an anal phallus. The pregenital superego is characterized by its severity and does not lead to a real identification. It is made up only of commands and prohibitions.

        Keep in mind that CBT is a manualize therapy. The CBT practitioner has internalized a collection of commands or precepts. “If the patient has a pessimistic thought, provide an alternative optimistic thought.” These precepts are enforced rigidly by the therapist without any regard as to the meaning or value of any particular intervention. It’s the same dynamic we see in authoritarian personalities, who are people who have internalized commands or precepts without any regard to the meaning or value of the command. “It is wrong to question authority. Period.” But what if the authority is corrupt? What if the authority is incompetent? What is the authority is malevolent? These are all irrelevant considerations to the authoritarian personality, since that person has simply internalized the bare precept, “It is wrong to question authority.”

        I have seen three CBT therapists and my experiences with each of them confirms the extreme rigidity of their thinking and their inability to explain the value of their interventions. Their response is always more or less, “Just do what I say.”

  7. Anonymous

    I have worked with various therapists, psychiatrists, and psychologists (who are therapists, but I, distinguishing them by their education and only as a referent, not a judgment. I have PTSD and am a survivor of childhood trauma and trauma throughout much of my adult life that stemmed from severe childhood sexual and ritualistic abuse, primarily. I have tried CBT with practitioners in all of nearly all of the aforementioned categories. None of it was helpful. It made me question the validity of every thought I had, even ones that were signs of recovery. I once had a therapist tell me that I had to refrain from using any words like “not, never, and no,” and that I should always reframe these things in a positive way. When I asked her about a sentence like “what about saying that people shouldn’t abuse children,” she yelled, “Stop! Reframe that without using a negative word.” I fail to see how this was remotely helpful, and it actually resulted in a setback because I was not even sure I had the right to feel that what was done to be was wrong. I have since found a very good treatment team, some of who, have confessed to being survivors of various kinds of trauma, and none of them felt CBT was particularly useful or appropriate, especially with respect to trauma. I have yet to hear what the “positive reframing” of the idea that abuse shouldn’t occur is. I, sorry if I sound cynical, but many people (some who had an awful lot of authority) tried to convince me to try CBT over and over, and it did nothing but frustrate my efforts to heal. It should never be the standard or universal course of treatment in my opinion, particularly in the case of trauma. If it helped someone, I’m glad, but after doing a lot of research and also talking to many patients and clinicians over several decades, I do not believe CBT is appropriate or helpful on treating trauma.

    • Dear Anonymous, I’m not sure why CBT is so popular. I think because it’s cheap, and can be manualized (put in a manual) so that a minimally qualified professional can do it. Places like the Mayo Clinic recommends it. I think the real reason is that it takes lot of time and attention to help someone with PTSD, and CBT seems like a quick fix. I’m sorry you had such a bad experience with it; I’ve yet to hear from anyone with a good experience. Take care. Fred

  8. Klaudia Patrycja

    Dear Professor Alford,

    The part of “What Evil Means to Us” where you write:

    “In the sadistic act, the sadist seals his dread in the body of the victim, the victim becomes coffin, the victim’s suffering the sadist’s testament to his will to survive his pain.”

    meant a great deal to me. As someone who had the Heinz 57 of child abuse, including being tortured as a child, I have found that your writing gets at the heart of the experience of torture in a way that nobody else’s does. I feel very lucky to come across your work.

    After I read that, I decided that I wanted to make my life a testament to my will to survive my pain – not by the testament of my sadism, but by its opposite. To demonstrate that even torture could not destroy my capacity for love and forgiveness (including towards myself).

    Thank you so much for what you’ve given me.

    • C. Fred Alford

      I’ve been surprised at how many people have said they were tortured as a child. I also heard this in the interviews I did for “What Evil Means to Us.” The great thing is to break the chain, and to consent (as we all must) to being a victim, and then get on with life. I think that’s why Simone Weil appeals to me. See my godblog entry, https://godblog.org/simone-weil-and-donald-trump/. Thanks for such a touching response. Fred

  9. […] prolonged exposure therapy and virtual reality exposure therapy (p 256).  Not only are these some of the worst therapies around, but they are popular for the wrong reasons: because they are short, cheap, and can be easily […]

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