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The Gold Standard Should Work With Real Clients

A slide in one of our training programs used to list prolonged exposure (PE) as “the gold standard” of trauma therapies, but then we took out the “g.” For two reasons. One is that eye movement desensitization and reprocessing (EMDR) has now surpassed PE, in acceptability to clients as well as efficiency (Greenwald et al, 2016). The other is that the gold standard trauma therapy should be useful with real clients, and it’s not clear that PE is.

The so-called gold standard trauma therapies were established on the basis of randomized controlled trials, with EMDR, and other cognitive-behavioral therapy variants such as cognitive processing therapy (CPT) leading the pack. Both PE and CPT have now been implemented on a large scale in the field, mainly in settings that treat veterans and active military service members. Lisa Najavits recently published a review of those gold-standard therapies for PTSD as implemented in real-world settings (Najavits, 2015). The focus on real-world settings is important, because the dropout rates reported in controlled studies of trauma therapy might not apply to typical practice settings.

Najavits found that – depending on the study – only 2% – 28% of participants in real-world treatment settings completed their PE or CPT. This horrifically low completion rate means that most people who go for PE or CPT don’t actually get the help they need. As PE and CPT are apparently not generally acceptable to clients and/or therapists, they should not be considered gold standard treatments. Because what’s the point of calling something a gold standard treatment if it cannot be used?

Whereas EMDR has a lower dropout rate than PE in controlled comparison studies (Greenwald et al), EMDR has not yet been studied in large-scale implementations in real-world settings. Such studies would be of great interest, especially since PE and CPT have not come through.

It does take some effort, but it’s not very difficult to track treatment retention and outcomes in real-world settings. We have been doing this in our own clinic, within our grant-funded Intensive Trauma-Focused Therapy for Victims of Crime program. We assess our clients’ presenting problems as well as their post-traumatic stress and related symptoms, at pre-treatment, two weeks post-treatment, and 12 weeks post-treatment. All four of our therapists in this program are trained in EMDR and/or progressive counting (PC), as well as our intensive therapy model. Prospective clients are screened in based on their eligibility: living in the catchment area, and having experienced a qualifying event. Prospective clients are screened out if they do not qualify, or if their treatment is likely to take too long (due to the constraints of our grant funding). However, our clientele still includes many people with problematic attachment, complex PTSD, and other serious problems. We do not focus only on the index event; rather, we typically treat the client’s entire trauma/loss history.

In the program’s first year, of the 55 clients who commenced treatment, four dropped out, 13 were still in progress (e.g., additional scheduled day/s yet to be completed), and 38 completed treatment. Completers averaged 30.1 hours of treatment, or just under four and a half days. Here are the results of the latest-completed post-treatment evaluations:

  • Problem Rating Scale, a client rating of their three primary presenting problems, on a 0-10 range with higher numbers representing more severe problems. The mean scores from pre-treatment to post-treatment went from 7 to 2.2.
  • Trauma Symptom Inventory, numerous subscales for PTSD, anger, anxiety, dissociation, etc. The mean number of symptom scales in the clinical (pathological) range pre-treatment to post-treatment went from 9.8 to 1.7, with over half the clients having no remaining scales in the clinical range.
  • Stability & Ability Scale, 1-5 range with higher numbers representing more severe problems. The mean scores from pre-treatment to post-treatment went from 3.1 to 1.5.
  • Client Satisfaction Scale, 8-32 range with higher numbers representing greater client satisfaction. The mean score at posttreatment was 31.2.

In sum, we utilized manualized research-supported trauma therapies, we retained most of our clients, and those who did complete treatment got a lot better.

These results are not of sufficient quality to be reported in a peer-reviewed publication. Some participants did not complete their post-treatment assessments (though their outcomes, as per their communications with their therapists, were also excellent). We modified some of the assessment strategies along the way. Etc. Hopefully by the second year we’ll be more consistent in our evaluation process.

The point is that – as Najavits has suggested – a trauma therapy should not earn the gold standard designation until it has been found to be efficacious in randomized clinical trials, and been found to be effective, as well as acceptable to clients and therapists, in real world settings. If PE and CPT, as presently practiced, can’t do the job, they should be improved. And perhaps EMDR, PC, and/or other treatments will ultimately prove to truly merit the gold standard designation.


Greenwald, R., McClintock, S. D., Hall, S. L., Verbeck, E. G., Lamphear, M. L., Seibel, S., Doss, J., Halvorsen, L., & Gray, A. K. (2016). A meta-analytic comparison of EMDR to other trauma treatments: Effectiveness, efficiency, and acceptability to clients. Manuscript in preparation.

Najavits, L. M. (2015). The problem of dropout from “gold standard” PTSD therapies. F1000Prime Reports, 7, 43. DOI: 10.12703/P7-43