NJ Psychological Association challenges APA Clinical Practice Guideline for the Treatment of PTSD


quick takes

ptsd guidelinesThe APA guidelines can be found here 

From: Charity Wilkinson <wilkinson.charity@gmail.com>

Subject: [abct-members] APA PTSD Clinical Practice Guideline Being Questioned by NJPA

Date: December 22, 2017 at 7:44:44 PM CST

To: ABCT Member List <abct-members@lists.abct.org>

Reply-To: ABCT Member List <abct-members@lists.abct.org>

Dear Colleagues,

I’m writing to bring to your attention that the NJ Psychological Association issued statement today indicating that they sent a message to the APA expressing concern about the Clinical Practice Guideline for the Treatment of PTSD. This action was taken when a group of over 75 psychologists in NJ signed a letter opposing the Guideline. Though many of us sent statements to the NJPA supporting the Guideline, our statement was ignored.

The NJPA’s statement advocates for psychologists practicing from psychodynamic and other orientations who believe that their work has been wrongfully excluded. They have indicated that they fear the loss of their livelihood, insurance companies not funding their work, and the opportunity for clients to receive psychodynamic and other treatments that were not included. The statement also suggests that all treatments yield results and that RCT’s should not have been as strongly considered in the development of the Guideline.

I would ask that ABCT members and perhaps leadership create a statement in support of the APA PTSD Guideline.

Thank you for your consideration.


Charity Wilkinson-Truong

This is why APA has been so reluctant to take a stand and set guidelines about what is evidence-based psychotherapy and what is not.

See my post of a while ago (2012)

Troubles in the Branding of Psychotherapies as “Evidence Supported”


Is acceptance and commitment therapy (ACT) in a post-evidence phase?

Steve Hayes encouraged me to give the evidence for the efficacy of ACT another look. I did and I wasn’t impressed.

Recent interviews with three founders of ACT make little reference to evidence, but a lot of reaching for roles as gurus, not as trainers in evidence-based therapy.

I recently tweeted about acceptance and commitment therapy (ACT).

my tweet

I got a quick reply from Steve Hayes:

edited steve hayes exchange

I checked the document, and had lots of numbers, but little indication of accumulating quality studies. I recognized some of the meta-analyses were quite bad.


The document listed 2 organizations that describe ACT, or areas of ACT, as evidence based, APA Division 12 and SAMHA. Both sourceds depend heavily on promoters of a particular approach assembling and evaluating material, with all the biases that that introduces, not independent, systematic evaluation. The APA page was written by an ACT his enthusiasts, but was nonetheless not particularly impressive. Only ACT for chronic pain received an evaluation of more than modest support.

American Psychological Association, Society of Clinical Psychology (Div. 12), Research Supported Psychological Treatments.

Chronic Pain – Strong Research Support

Depression – Modest Research Support

Mixed anxiety – Modest Research Support

Obsessive-Compulsive Disorder – Modest Research Support

Psychosis – Modest Research Support

I checked the most recent review and meta analysis of ACT for chronic pain.

Veehof MM, Trompetter HR, Bohlmeijer ET, Schreurs KM. Acceptance-and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review. Cognitive Behaviour Therapy. 2016 Jan 2;45(1):5-31.

The review combined  28 studies evaluating mindfulness or ACT. It did not provide separate evaluations for the two treatments. There were 9 studies comparing ACT to routine care or wait list. Only one had more than 35 patients in the smallest group at follow up, a study of ACT with fibromyalgia patients. There was one study comparing  ACT with CBT having such a minimal sample size, and the two treatments did not differ. There were two comparisons with multidisciplinary treatment, but neither met this minimal sample size.

A systematic review that is almost as recent further showed what bad shape the literature concerning ACT for pain is in.

Hann, K. E. J. & McCracken, L. M. (2014). A systematic review of randomized controlled trials of Acceptance and Commitment Therapy for adults with chronic pain: Outcome domains, design quality, and efficacy. Journal of Contextual Behavioral Science, 3, 217-227.

The review discretely suggests that the weak designs and potential for p-hacking of the typical study of ACT for pain would allow even homeopathy to look better than nothing.

A systematic search identified 1034 articles and ten studies were selected as eligible for review. Overall, 15 outcome domains were assessed using 39 different measurement tools across the ten RCTs. The outcome domains assessed in the reviewed trials were, to an extent, in-line with recognized guidelines. Six of the ten studies identified primary and secondary outcomes; one included just one outcome and three did not categorize outcomes. All ten trials included a measure of some aspect of psychological flexibility; however these were not always formally identified as process variables. Pain and emotional functioning were the most frequently measured outcome domains. A review of outcome results suggests that ACT is efficacious particularly for enhancing general, mostly physical functioning, and for decreasing distress, in comparison to inactive treatment comparisons. It is recommended that future RCTs (a) formally define outcomes as primary, secondary and process variables, (b) consider including measures of physical or social functioning, rather than pain and emotional functioning, as primary outcomes, (c) address existing risks of bias, such as reporting bias, and (d) include more components of psychological flexibility, such as cognitive defusion and self-related variables.

Are the leaders of the ACT movement giving up on accumulating evidence and reaching for guru status? Maybe, if some recent interviews are any indication.

3 Founders of ACT in BPS Psychologist

Aseries of interviews by Kal Kseib with three founders of ACT can be found in the BPS Psychologist– Kelly Wilson, Kirk Strosahl and Steve Hayes.

Kelly Wilson

The title of the interview with Kelly Wilson suggests he is going to pluck some flowers stuck between his toes in his Gucchi sandals 

Kelly you find some connection

Kelly doesn’t disappoint.  He does mention evidence three times. Twice here:

There’s interesting evidence out there about how even just small doses of such things can make a difference. In research looking at sedentary behaviour, just a couple of minutes each hour of getting up and moving around is shown to disrupt some of those destructive metabolic processes. Reducing exposure to toxins including social toxins, moving your body, getting enough sleep, eating nutritious food, engaging in some small mindfulness practice – every bit of evidence seems to suggest that really small amounts matter. And if you look at behavioural activation, which is one of the tier 1 treatments for depression, it’s about ‘get them started’. The smallest thing – even if just your feet move! Go down to the corner, go out for coffee, go out to a movie with a friend. That work was really built on the idea that these patterns of small activities give a chance for the stream of life to kind of pull you back in.

And then

For instance, there’s evidence to show that people with high levels of self-stigma about their obesity massively increase their risk of all-cause mortality and cardiac mortality.

I wouldn’t interpret modest effect sizes in observational studies in this way. But whatever….

Then there is the too-much-information, grab-your-guru-status disclosure.

What’s something people might not know about you that, if they knew, would surprise them?

I came to psychology late. I was 30-years-old when I started college. I dropped out of school when I was 16. And between the ages of 16 and the age of 30, I was a drug addict and an alcoholic. Chronically unemployed and unemployable – a serial felon. Terribly, terribly depressed – suicidally depressed pretty much all the time, except for little glorious windows in time when I’d get just the right combination of drugs and I’d be able to feel like I could stay in my own skin for a minute. But mostly it was just hard and destructive to me and to a lot of other people. In 1985, at the age of 30, after many years of overdoses and car accidents and violence, illness, and just wanting to die, I was admitted into a locked psychiatric ward. I joke with people sometimes – although it’s true – that I got my start in psychology in a psychiatric hospital

I have written about aspiring TED talk gurus like Amy Cuddy and Kelly having to find their redemptive selves, linking the product they sell to overcoming the adversity in their lives. I think there may be some literary license in play here, but if it is meant to inform, rather than just entertain, what is the takeaway message?

What is the greatest lesson life has taught you recently?

That the things you love the most are also the things that are the sources of the most extraordinary pain possible. And there is no greater joy or pain life can deliver than that you get from your children. Sweet and sad, poured from the same vessel in equal measure.

What motivates you to inspire self-care in others?

I lost my eldest brother Randy in 1987 to suicide. Since then, I lost my brother David in 2011 to a cerebral haemorrhage, and my baby brother Michael in 2013, to a heart attack. In 1998 I was given a head and neck cancer diagnosis. My interest in self-care, kindness and wellbeing is not a casual interest, it has to do with me, it has to do with the people who I love, both the ones who I know, the ones I’ve lost, and the ones who I don’t know yet.

Kirk Strosahl

Maybe he is just being flippant, but I was uncomfortable with the strong, but implicit suggestion of Kirk’s title that people chose to suffer.

Kirk pain is inevitable

How would you describe ACT in a nutshell?

I think ACT tries to promote people who are open to their own experience and can separate themselves from the literal meaning of their experience – so that they’re not governed by thoughts or feelings or emotional reactions to things. They are in touch with their personal values so that they are geared toward living life to its fullest.

What are your most inspired actions?

I think the time I truly felt the most inspired simply in terms of output was writing my most recent book, Inside This Moment. I was in a zone for the entire time that I was writing it, it was coming from the heart. It was actually quite an amazing experience. The book zeroes in on how to use the present moment in therapy to inspire people to live their lives to the fullest, and not to run from their own demons, but rather cradle them. So that was enjoyable. Then I’ve also always been inspired to work with Patti [Dr Patricia Robinson]. We have a lot of fun and there’s intellectual growth when we write and get our arms around stuff together. So I’ve been very lucky that way.

Where are ACT and the other so-called ‘third-wave therapies’ heading now?
I think people are going to have to get their arms around what we mean by ‘mindfulness’ in a much more scientifically sound sense. Not the term, not the popular concept, but understanding exactly what goes into it. We’re still very overly general about it in our conversations, and because of that we’re losing leverage in therapy that we would otherwise gain by being more discriminating. That’s one area I think is going to see a lot of further growth. And I think we’re going to be looking at how we get our treatments briefer without losing effectiveness, because resource systems out there simply can’t afford the longer-term version of CBT or ACT for the masses – that’s another big area. How are we going to populate these concepts into public health models and work with lay people, primary care providers and teachers, for example? We’re still very therapist-centric in our profession, and because of that our population health effectiveness has been extremely limited.

I think the other area that is going to become bigger and more important is values-based behaviour change. It’s not like people haven’t been exploring it, but I think the amount of development will increase. There are measurement issues that are going to have to be dealt with, as well as creating more efficient ways of talking to people about motivating factors in their lives.

Kirk is modest in his aspirations for ACT, but I don’t see the relevance of evidence.

What is the greatest opportunity ACT has in today’s world?

I actually think that, if we don’t fall on our own sword, it’s going to be about bringing mindfulness concepts into the general public and Western civilisation. That’s not going to mean getting everybody in the West to put in hours of practice a day, sitting on a pillow ‘umm-ing’. Rather it’s this idea that these are actually pretty portable interventions based on neuroscience. They have a very rapid effect on brain neural pathway development and brain efficiency, and they don’t have to be these onerous, lifelong practices. There’s going to be a huge opportunity there if we can get the right message to people – that these are things you can teach yourself and your brain in small bits, and that it’s more about persistence than the amount of time you take. It’s about doing things intentionally and practising intention, as well as practising paying attention. These two things go hand in hand in mindfulness – this ability to pay attention in a particular way and then to act with intention inside of your own space. To me those things are so intricately linked to psychological health that if we could get those out into the public domain in ways which didn’t seem overwhelming to people, that would be a huge accomplishment for ACT, or for any of the mindfulness-based therapies that could get this figured out. So it isn’t just in the hands of a few peopl

Are ACT and CBT actually little more than saying to people ‘live with it, or change it’?
There are hidden properties of treatments, and then there are the observable properties of treatments. In ACT the observable properties are quite different, with an emphasis on values. It’s saying to people ‘don’t just tolerate your life, build your life from within’. ACT uses values as a foundation for addressing that.

Then there’s the ability to create space between you and what starts to show up in your life when you start doing things that matter. It’s an optimistic treatment that assumes people can do amazing things if they get lined up behind the right psychological processes. And it might well be that in CBT, even though ostensibly focusing on helping people change thoughts and behaviours, the act of talking about thoughts and behaviours is in a way itself a kind of a ‘defusion’ intervention. That’s what I mean by ‘hidden’ properties. You think that the mechanism is about the client becoming more logical and less irrational, but it may in fact be that by talking about thoughts you’re actually doing ‘defusion’ without even realising it.

I am also uncomfortable with the message that effective therapy can be delivered in 15 minutes. I am sure it sells well in behavioral health settings or in neoliberal societies where the goal is to underfund mental health services, but claim to offer them broadly. But strong claims with such potentially socially pernicious implications need very strong evidence. I have searched and can find none.

You’re a specialist in delivering brief, or ‘focused’ ACT interventions to patients – sometimes as brief as 15 minutes. Could you give a picture of what you might focus on in a session, say for diabetes or depression?
The goal of focused ACT is to get patients to make direct contact with the unworkable results of their current life strategies. Usually, these strategies involve avoiding dealing with important life issues – such as maintaining social health, managing diet or other health risk behaviours in the case of diabetes. The counter-weight in focused ACT is to get the patient to make direct contact with what matters to them in their life, and whether their avoidance behaviours are helping them move in that direction. This discrepancy creates a ‘healthy anxiety’, which we encourage patients to accept as a ‘signal’ that some type of change in personal strategy is needed. You don’t get people to change behaviours by giving them a label, or scaring them with adverse consequences if they don’t change, or lecturing them about the necessity of change. Change comes from within, not from without. Most patients know implicitly that they are avoiding things, but they don’t want to be condescended to, criticised or cajoled about it. So focused ACT is a very humanising approach in which we readily agree that making important changes in life might likely trigger painful emotional consequences or distressing memories of past failures, et cetera. Pain is inevitable, but suffering is optional.

The therapist and patient are on the same journey in this, and they’ve just happened to run into each other. There is no difference really between us.

Steve Hayes

Last, but certainly not least, Steve’s interview is titled with a rhetorical question that he does not get around to answering.

steve why can't we

How do your ideas connect with your values?

I’ve tried in my career to be less concerned about brand names and personal applause, and more concerned about building community and connecting to this larger value of ‘how can we best serve people using science?’. I get more excited in my personal work about supporting the work of others. I mean I’m productive, I do research, I write books. But to this day I’ve never not responded to an email. If a patient contacts me and says, ‘I’m in misery, what do I do?’: yeah, it might be two or three sentences, but I’m going to try and do something. So my value is being of use and building a community that can profoundly be of use – trying to bring science into alignment with what society needs and wants from us. And I don’t think we’ve always served that.

Surely, you jest, Steve.

You’re one of the founders of acceptance and commitment therapy, or ACT. What is the greatest opportunity ACT has in today’s world?

Reaching the culture. My son’s favourite cartoon show is Steven Universe – it’s very sweet. Garrett is a kind of a meditation or mindfulness person, a wise adult. She sings a song called ‘Here comes a thought’, and the show notes say she got it from ACT. The first stanza is ‘flexibility, love and trust’, and it walks through what to do with difficult thoughts. It talks about seeing and feeling, and watching the thought. And they actually lie on the ground like they’re watching clouds. I started crying seeing it because I’m thinking, ‘how many children have shame that they’re carrying?’ It’s got to be a large percentage of children, right? And they can’t talk to their parents, and they can’t talk to their peers, because what is it they’re going to say? ‘Just don’t think about it.’ And it’s like pouring gasoline on a fire, it’s just a horrible thing to do to shame… it’s saying there’s something wrong with you for feeling and thinking that, and you just need to think differently and it’ll go away. We can do something a lot wiser than that.

When I teach brand new students, say, research methods, the very first thing I get across is this: the modal number of citations for a publication in psychology is zero, which means nobody has been influenced by it enough to actually put in writing that it mattered. So I only want something that you really have heart for, something that deep down you think might really matter. And then I tell them, ‘and by the way, your research idea almost certainly is a bad idea’, because that’s how it [the modal number of citations] gets to zero. From there we can figure out a way that maintains the heart, and that won’t have zero citations. There’s like this dialectic of ‘how do we come into our field as social human beings with this core of caring, and nurture and sustain that, but also learn how to channel our interest and questions in a way that will have a long term impact on the world – on our clients and on our colleagues?’.

What’s something people don’t know about you, that if they knew, they would be surprised?
I think people are sometimes surprised that if I wasn’t going to be a psychologist, my other big thought about what I would be is a carpenter. I’m a veteran re-modeller, I’m tearing down my house all of the time. People sometimes think I’m a geek, but I can put in plumbing and I’ve built an entire house from nothing, from the foundation to the roof – done everything myself. So I’m a builder and I try to bring that sensitivity into what I do research-wise and clinically also. I want to build something that lasts and that matters, and I think we’ve been able to do it in some of the work we’ve been doing in CBT and ACT, and Mindfulness and ACBS etc.

I can’t add to this. I will just let Steve speak for himself.

The RCT of tango dancing versus mindfulness meditation for depression

giphy1If someone is unhappy with their life, should they take up mindfulness meditation or some other activity?

That is a question that a lot of people confront. For an answer, they might even look to this RCT comparing tango dancing lessons to mindfulness to a waiting-list control.

The authors actually specifically asked whether tango dancing is as effective in reducing stress, anxiety, and depression as mindfulness meditation. Furthermore, they raise the question whether tango dancing increased mindfulness more than meditation itself.

The authors did not actually produce a direct answer to the questions they raised, but what happened is interesting to me, even if my interpretation is counter to the authors.

In the end, if this RCT provides any answers at all, it is “if you’re trying to decide what to do to resolve unhappiness, you might want to select an activity that you enjoy participating in, for itself.” And I really don’t think you need an RCT to guide that decision.

But further investigating this RCT can provide some useful insights about interpreting such studies, because there are many out there like it.

Certainly one take away lesson is that we should pay more attention to the CONSORT flowchart when we began evaluating a report of an RCT than we typically do.

The citation and the access to a PDF of the study is directly below.

Pinniger R, Brown RF, Thorsteinsson EB, McKinley P. Argentine tango dance compared to mindfulness meditation and a waiting-list control: A randomised trial for treating depression. Complementary Therapies in Medicine. 2012 Dec 31;20(6):377-84.

Objectives: To determine whether tango dancing is as effective as mindfulness meditation in reducing symptoms of psychological stress, anxiety and depression, and in promoting well-being. Design: This study employed analysis of covariance (ANCOVA) and multiple regression analysis. Participants: Ninety-seven people with self-declared depression were randomised into tango dance or mindfulness meditation classes, or to control/waiting-list. Setting: classes were conducted in a venue suitable for both activities in the metropolitan area of Sydney, Australia. Interventions: Participants completed six-week programmes (1½h/week of tango or medita-tion). The outcome measures were assessed at pre-test and post-test. Main outcome measures: Depression, Anxiety and Stress Scale; The Self Esteem Scale; Satisfac-tion with Life Scale, and Mindful Attention Awareness Scale. Results: Sixty-six participants completed the program and were included in the statistical anal-ysis. Depression levels were significantly reduced in the tango (effect size d = 0.50, p = .010), and meditation groups (effect size d = 0.54, p = .025), relative to waiting-list controls. Stress levels were significantly reduced only in the tango group (effect size d = 0.45, p = .022). Attending tango classes was a significant predictor for the increased levels of mindfulness R2 = .10, adjusted R2 = .07, F (2,59) = 3.42, p = .039. Conclusion: Mindfulness-meditation and tango dance could be effective complementary adjuncts for the treatment of depression and/or inclusion in stress management programmes. Subsequent trials are called to explore the therapeutic mechanisms involved.

There are a number of deficiencies in this abstract as a representation of the study, but let’s put them aside for now.

The take away message that seems to be intended is that in some respects the tango group and meditation groups similarly reduce depression, and the tango group increased mindfulness. On Twitter, a lot of attention was given to the interpretation that only the tango group reduced stress.

Ratonale for the study.

If you are interested, you can read this passage in its context, but the authors offer an interesting rationale for their study

Toneatto and Nguyen17 suggest that any activity requiring awareness of current experience is likely to interrupt an individual’s thoughts about their past and fears about the future, so potentially lessening association between nega-tive thoughts and possible affective symptoms. Tango is one activity that could achieve this goal, since it is an absorb-ing activity that requires significant skills acquisition,8,16 and an awareness of current experience.17 It also facilitates an involvement in music, exercise, and touch, all of which have previously been reported to be effective in alleviating psychological distress.18—20

The important details of the recruitment

 The paper is actually better than most in describing explicitly what participants were told who were invited to enroll in the study.

Participants were recruited via advertisements asking for volunteers with self-reported stress, anxiety, and/or depression. They were invited to participate in a RCT evaluating tango dance relative to mindfulness meditation or waiting-listed control. They were advised that they could be allocated to one of those three groups.

Participating in an RCT or any research, for that matter, usually involves assuming some burden in terms of having to complete assessments and not drop out except for some good reason. But it also involves the gamble of randomization. Participants may be seeking an experience that they might not otherwise have available, and risking not being assigned to it, but nonetheless feeling obligated to stick with it.

We will soon be seen that most participants in the study were more interested in getting tango lessons than in becoming more mindful. Any hopes of interpretable results for a randomized controlled trial could been doomed from the start by a lack of equipoise- different participant valuation of tango lessons versus mindfulness at the outset, or it could have emerged once participants actually gotten involved in these activities. Regardless, different preferences and differences in the ability of the two interventions to retain participants were ultimately fatal for an interpretable findings, at least in terms of the outcomes of anxiety, depression, and stress.

The CONSORT flowchart

 consort flow tango

Most readers will skip over the CONSORT flowchart for these kind of studies. But it is good that most journals have accepted the requirement that reports of RCTs have such a flowchart. What is revealed about this study is that there were so many dropouts from participants assigned to mindfulness, much more that so than the tango group.

What is also interesting is that the waiting list group stuck around for assessments. I might’ve predicted ahead of time that assignment to this treatment would have the greatest number of dropouts because of the delay in getting any reward.

Inappropriate analyses.

The most appropriate and informative analysis for an RCT includes results for all participants who originally enrolled. That is an intention to treat analysis. Less preferable is what these authors did, an analysis limited to the participants available at follow-up.

In a situation of such different abilities of conditions to retain participants, many researchers would have resorted to some kind of imputation of missing data from what data were available. Such imputation typically assumes that loss to follow-up is random, which is unlikely. Aside from violation of this assumption, there is simply too few participants retained in the mindfulness group to provide a basis of guessing the outcomes of participants lost to the study. So, intent to treat analyses based on imputing outcomes to participants who were no longer available would be invalid.

But what the investigators did instead was similarly invalid. They ignored that a substantial portion of the participants assigned to mindfulness meditation were no longer available and analyzed only the results of those who stuck around. Consider this analogy of a climb up Mount Everest as a way of reducing stress. Most participants would make it, but would you make a decision about the value of attempting to climb Mount Everest based on results only from those who made it?

The voucher

 I did not pay attention to a key statement in the description of recruitment that later took on particular importance in interpreting what happened in the study. The statement was

What we were later told in the discussion section:

Finally, 97% of participants in the study chose to receive a tango dance voucher after the study, rather than a meditation voucher, suggesting the popular appeal of tango dance. This is an important consideration, since people tend to adhere to mindfulness-based programs more than other therapy approaches,22 especially if the experience is intrinsically positive,25 such as tango dance is reported to be.8

So, it appears that the participants recruited to the study had a strong preference for getting tango lessons, not mindfulness meditation. There was a broad dissemination of invitations to participate in the study. We’re not told, but maybe the researchers had to advertise so broadly, because they initially had difficulty obtaining participants. Maybe, –we are not the position to know–mindfulness was readily available in Sydney Australia, but tango lessons were in short supply. Participants enrolled in the study in hope of getting assigned to tango lessons.

Bad abstract

Having read the study, I could now see that the abstract was misleading. It left out the important detail of how many participants were recruited to the study instead focused on the number from whom results were available. Furthermore, I’m suspicious about the participants being described has self identified for depression. Most accurately, participants from were recruited for a study aimed at reducing anxiety, depression, and stress. They did not self identify as depressed, they simply filled out some self-report questionnaires. An even suspicious about depression being implicitly presented has the primary outcome. They could be confirmation bias here: it is the one of the three outcomes for which the results were strongest.

Back to the question of tango dance lessons versus mindfulness meditation

 Both dance lessons  and mindfulness meditation require commitment and practice to obtain benefit. I don’t think that participants enrolled in the study only to reduce their self-report measures. They expect to get something out of the experience. If nothing else, the dance lessons posed the prospect of leaving participants better able to dance. No guaranteed, of course, but it was in the offering.

So, back to a person pondering what to do with their life. The key issue is one of personal preference: do they think they are likely to engage in the activity enough to get any benefit? If the activity was supposed to produce something tangible, like dancing skills, would they be content with that alone? If a participant were only looking to have a bit of fun, would they really need the guidance of an RCT?