Treatment of Trauma: What the Evidence Says About EMDR and Trauma-Focused TCC

Few topics generate discussions as heated among colleagues as the treatment of trauma. Some consider the EMDR little less than pseudoscience and those who have it as the approach of choice. Some argue that exposing the patient to traumatic memory is retraumatizing and those who show that avoiding it is just what keeps the picture.

The evidence gathered today allows much of that discussion to be answered, and the result leaves several positions uncomfortable at the same time.

TL;DR

• The most comprehensive network meta-analysis (90 trials, 6.560 people, 22 interventions) identified DREM and trauma-centered CCT (TF-CBT) as the most effective treatments for post-traumatic stress in adults.
• Faced with the waiting list, EMDR showed SMD -2,07 and TF-CBT -1,46 at the end of treatment; both sustained the effect on 1 follow-up to 4 months.
• The Cochrane review (70 studies) coincides: Individual TF-CBT and EMDR are effective and exceed non trauma-centered therapies in follow-up.
• The overall quality of the evidence is described as moderate to low, especially by the size and design of many trials.
• The common denominator of what works is not the specific technique, it is working on traumatic material, not around it.

Why it Matters

In Argentina, much of the postgraduate trauma training is organized around schools and not by comparative evidence. That makes the choice of approach often follow the training available in the city rather than the state of research.

Knowing what the data show does not force you to change your model. It allows you to derive better when appropriate, explain to the patient why you propose what you propose, and recognize when a treatment is not having the expected effect.

What the evidence says

The network meta-analysis

Mavranezouli et al. (2020) published in Psychological Medicine a systematic review with network meta-analysis designed to inform a clinical guide. It included 90 trials, 6.560 people and 22 interventions different, with outcomes at the end of treatment, in follow-up of 1 to 4 months and remission rates.

The most effective treatments against the waiting list at the end of the treatment:

Other interventions also showed effects: non-trauma-centered CCT, TF-CBT combined with SSRI, medication alone, self-help without support, and counseling.

The data that weighs most clinically is not in the table: EMDR and TF-CBT were the two that maintained the effect on 1 follow-up to 4 months and improved remission rates. The authors concluded that both appear as the most effective for reducing symptoms and achieving remission in adults with post-traumatic stress.

The Cochrane Review

The Cochrane review by Bison et al. (2013), with 70 studies, reached convergent conclusions: there is support for the efficacy of individual TF-CBT, EMDR, non-trauma-centered CCT and group TF-CBT in chronic posttraumatic stress in adults.

And he added an important nuance on follow-up: while the first three were equally effective immediately after treatment, there was evidence that TF-CBT and EMDR were superior to non-trauma-centered CCT between one and four months later. That is, the difference does not appear at the end, appears when time passes.

What they have in common

This is the background finding, more useful than any ranking: the interventions that work best are those that directly address traumatic material, with different procedures. The ones that work around (generic stress management, nonspecific support) help, but less and with less support.

What does it mean in your clinical practice

• If you work with trauma, train on a trauma-centered approach. The choice between EMDR and TF-CBT can be guided by your training, availability of supervision, and patient preference: evidence does not require choosing one.
• Patient preference is not a detail. In trauma, adherence is fragile and early abandonment is high. A somewhat less "optimal" treatment that the patient sustains yields more than the optimal that he leaves in the third session.
• Stabilize before processing. The evidence compares complete treatments, which generally include stages of preparation. It does not say that you can go to traumatic memory in the first interview.
• Medium. In trauma more than anywhere. A periodically applied validated scale allows you to see if the processing is progressing or if the patient is deregulating, something that clinical impression alone can take long to detect. It is the logic of result monitoring.
• Document with special care. The medical records of trauma cases usually contain the most sensitive material that you are going to record in your professional life, often with legal implications. It is worth checking how you handle professional secrecy and where you keep those records.

Killings and limitations

• Moderate to low quality. Many trials have small samples, high risk of bias and comparisons against weak conditions.
• The researcher's alliance weighs. In the field of trauma it is common for those who develop a method to evaluate it, in all schools.
• The debate on eye movements is still open. There is active discussion about how much this specific component of EMDR contributes above the rest of the protocol. The whole package does not prove that each ingredient is needed.
• Complex trauma is another conversation. Most trials include post-traumatic stress stress from single or limited events. Evidence of complex developmental trauma, with comorbidity and chronic deregulation, is much scarcer.
• Few research in Latin American population, with the exception that these protocols have been implemented in very different contexts.

In summary

If there is a field where the evidence is reasonably ordered, it is this: for post-traumatic stress in adults, EMDR and trauma-centered CCT are the best-backed approaches, and their advantage becomes more visible in follow-up than at the end of treatment. Choosing between them is a clinical decision; that of working on trauma rather than surrounding it, less and less.

Working with trauma requires your full attention in the session, and leaves long and delicate notes for later. Brauni Prepare the draft for you to review and decide what is settled, with your encrypted records and under your control.

References

• Mavranezouli, I., Megnin-Viggars, O., Daly, C., Dias, S., Welton, N. J., Stockton, S., ... Pilling, S. (2020). Psychological treatments for post-traumatic stress disorder in adults: A network meta-analysis. Psychological Medicine, 50(4), 542-555. doi.org/10.1017/S0033291720000070
• Bisson, J. I., Roberts, N. P., Andrew, M., Cooper, R., & Lewis, C. (2013). Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database of Systematic Reviews, (12), CD003388. doi.org/10.1002/14651858.CD003388.pub4