The Economic Value Of Intensive Trauma Therapy

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February 26, 2015 at 10:34 AM

Economic value is an important consideration in obtaining mental health care. Nobody wants to spend more than they have to, and that applies to individuals as well as grant funders, insurance companies, or government agencies. I’ve found that the idea of “getting it done” via intensive trauma therapy appeals to many people, but some wonder about the cost. Fortunately, economy and quality are not necessarily in conflict: spending more up front for quality treatment can be far more economical than the alternatives.

Impact of Trauma

Trauma is among the leading public health issues in economic as well as social impact.

  • Adverse childhood experiences (such as abuse, neglect, loss, exposure to violence, etc.) incur risk for lifelong emotional, behavioral, and medical problems, with each additional type of adverse experience exponentially increasing risk (Anda et al, 2006)
  • Traumatic experiences at any age (including crime victimization, rape, motor vehicle accident, etc.) potentially cause a range of enduring symptoms such as post-traumatic stress, anxiety, depression, anger, aggression, substance abuse (Friedman et al, 2007).
  • Domestic abuse (domestic violence & child abuse) costs the country an estimated $500 billion per year in medical expenses alone, not counting the economic impact of lost work, lost potential, family disruptions, and lowered quality of life (Goldstein, 2014).
  • Trauma, broadly defined, causes or contributes to nearly every type of emotional or behavioral problem, including mental illness, suicide, school/work failure, substance abuse, aggression, and crime (Friedman et al; van der Kolk, 2007).

Coping vs. Healing

Most psychotherapy focuses on stabilization and coping/self-management skills. While this can be useful, the underlying traumatization persists, potentially contributing to ongoing problems and risks. Thus treatment benefits are limited, gains may deteriorate, and further courses of treatment may be needed (Ecker, Ticic, & Hully, 2012). The preferred alternative is effective trauma therapy, which reliably mitigates or eliminates the harmful effects of traumatization (Bisson & Andrew, 2007), leading to profound and lasting change (Ecker et al). While clients may appreciate learning ways to cope with their symptoms, they prefer healing from the traumatization and no longer having to cope with their symptoms. And with healing, further treatment is not needed.

Recent meta-analyses have found eye movement desensitization and reprocessing (EMDR; Shapiro, 2001) to be more effective and more efficient than the other well-established trauma treatments (Greenwald, Hall et al, 2015; Ho & Lee, 2012). It is also well tolerated by clients, including children (Greenwald, Hall et al). Progressive counting (PC; Greenwald, 2013c) is a newer trauma therapy that has been found to be as effective as EMDR (Greenwald, McClintock, & Bailey, 2013; Greenwald, McClintock, Jarecki, & Monaco, 2015), less difficult for clients, and substantially more efficient (Greenwald, McClintock, Jarecki, & Monaco, 2015). Thus although there are several good options, EMDR and PC are arguably the preferred trauma treatments.

Cost-Benefit of Trauma Therapy

Therapy more than pays for itself by reducing medical costs; and greater cost benefits are realized when a) the clients are at high risk for expensive service utilization, and/or b) the therapy is research-supported and properly done (Levant et al, 2006). Providing effective therapy can also yield economic benefits due to reduced substance abuse, crime, and incarceration (Sheidow et al, 2012). Effective trauma therapy is likely to yield even greater cost-benefit than other types of therapy, because it is more effective (Ehlers et al, 2010), and has more durable results. One recent study found that providing (one of the slower methods of) effective trauma-focused therapy, while more costly up front (compared to standard care), still yielded substantial savings even on mental health expenditures, by reducing the need for high-cost expenditures such as residential care (Greer et al, 2014). Thus investing in effective, efficient trauma therapy, while improving recipients’ quality of life, can also be expected to yield a net financial gain, in one or more of the following ways:
∙    reduced medical expenditures
∙    reduced direct expenditures on mental health services, compared to standard care
∙    reduced community costs related to substance abuse, aggression/offending, and crime
∙    reduced personal costs related to underachievement, unemployment, and family disruption

Intensive Trauma Therapy

Whereas the traditional hour-per-week therapy format is suitable for working on coping skills, trauma healing does not require a slow, incremental approach. Some therapists using methods like EMDR and PC now offer therapy in an intensive format typically involving many hours per day for consecutive days. Advantages of intensive therapy include treatment efficiency, reduced risk of treatment-related destabilization, reduced risk of life crises disrupting treatment, and rapid results which preclude further suffering or harm from the symptoms (Greenwald, 2013a). The economy is compelling: even compared to other trauma therapy, the intensive format roughly halves treatment time, because of time not spent on a) checking in at the beginning of each session, b) addressing current crises and concerns, c) focusing on stabilizing and coping skills that the client won’t need after trauma healing, or d) assisting the client in regaining composure at the end of the session.

Numerous cases of successful intensive trauma-focused therapy have been reported (Ehlers et al, 2010; Gantt & Tinnin, 2007; Greenwald, 2013b,c, 2014b; Grey, 2011;  Hendriks, de Kleine, van Rees, Bult, & van Minnen, 2010; Lobenstine & Courtney, 2013; Wesson & Gould, 2009), including some with children and adolescents (Greenwald, 2013b,c, 2014a). A large, well-designed randomized study found that an intensive 1-week course of evidence-based PTSD therapy had the same outcome as delivery of the same treatment over several months; except of course that the results were achieved much more quickly in the intensive format (Ehlers et al, 2014).

The bottom line: trauma costs; healing saves; and quick, efficient, effective healing saves the most. Intensive trauma therapy can be a high quality treatment and a wise investment that more than pays for itself.

References

Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C., Perry, B. D., Dube, S. R., & Giles, W. H. (2006). The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical Neuroscience, 256, 174-186.

Bisson, J., & Andrew, M. (2007). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003388. DOI: 10.1002/14651858.CD003388.pub3.

Ecker, B., Ticic, R., & Hulley, L. (2012). Unlocking the emotional brain: Eliminating symptoms at their roots using memory reconsolidation. NY: Routledge.

Ehlers, A., Bisson, J., Clark, D. M., Creamer, M., Pilling, S., Richards, D., Schnurr, P. P., Turner, S., & Yule, W. (2010). Do all psychological treatments really work the same in posttraumatic stress disorder? Clinical Psychology Review, 30, 269-276.

Ehlers, A., Clark, D. M., Hackmann, A., Grey, N., Liness, S., Wild, J., Manley, J., Waddington, L., & McManus, F. (2010). Intensive cognitive therapy for PTSD: A feasibility study. Behavioural and Cognitive Psychotherapy, 38, 383–398.

Ehlers, A., Hackmann, A., Grey, N., Wild, J.,  Liness, S.,  Albert, I., Deale, A., Stott, R., &  Clark, D. M. (2014). A randomized controlled trial of 7-day intensive and standard weekly cognitive therapy for PTSD and emotion-focused supportive therapy. American Journal of Psychiatry, 171, 294-304.

Friedman, M. J.,  Keane, T. M., & Resick, P. A. (Eds.) (2007). Handbook of PTSD: Science and practice. New York: Guilford Press.

Gantt, L. M., & Tinnin, L. W. (2007). Intensive trauma therapy of PTSD and dissociation: An outcome study. The Arts in Psychotherapy, 34, 69-80.

Goldstein, B. (2014). The Quincy solution: Stop domestic violence and save $500 billion. Bandon, OR: Robert Reed.

Greenwald, R. (2013a, November 4). Get better faster! (for real) [Blog post]. Retrieved from http://www.childtrauma.com/blog/get-better-faster/

Greenwald, R. (2013b, December 2). Intensive treatment comes in really handy when... [Blog post]. Retrieved from http://www.childtrauma.com/blog/intensive-treatment/

Greenwald, R. (2013c). Progressive counting within a phase model of trauma-informed treatment. New York: Routledge.

Greenwald, R. (2014a). Intensive child therapy to prevent further abuse victimization: A case study. Journal of Child Custody, 11, 325-334.

Greenwald, R. (2014b, July 1). Mental illness or posttraumatic stress? [Blog post]. Retrieved from http://www.childtrauma.com/blog/mental-illness-or-pts/

Greenwald, R., Hall, S. L., McClintock, S. D., Siebel, S., Doss, J., Halvorsen, L., Lamphear, M. L., Priest, E. G., & Gray, A. K. (2014). A meta-analytic comparison of EMDR to other trauma treatments: Effectiveness, efficiency, and acceptability to clients. Manuscript in preparation.

Greenwald, R., McClintock, S. D., & Bailey, T. D. (2013). A controlled comparison of eye movement desensitization & reprocessing and progressive counting. Journal of Aggression, Maltreatment, & Trauma, 22, 981-996.

Greenwald, R. & McClintock, S. D., Jarecki, K., & Monaco, A. (2015). A comparison of eye movement desensitization & reprocessing and progressive counting among therapists in training. Traumatology, 21, 1-6.

Greer, D., Grasso, D. J., Cohen, A., & Webb, C. (2014). Trauma-focused treatment in a state system of care: Is it worth the cost? Administration and Policy in Mental Health, published on line; no page or issue # yet.

Grey, E. (2011). A pilot study of concentrated EMDR: A brief report. Journal of EMDR Practice & Research, 5, 14-24.

Hendriks, L.,  de Kleine, R., van Rees, M., Bult, C., & van Minnen, A. (2010). Feasibility of brief intensive exposure therapy for PTSD patients with childhood sexual abuse: a brief clinical report. European Journal of Psychotraumatology, 1, 5626 - DOI: 10.3402/ejpt.v1i0.5626

Ho, M. S. K., & Lee, C. W. (2012). Cognitive behaviour therapy versus eye movement desensitization and reprocessing for post-traumatic disorder: Is it all in the homework then? Revue Européenne De Psychologie Appliquée/European Review of Applied Psychology, 62, 253-260.

Levant, R. G., House, A. T., May, S., & Smith, R. (2006). Cost offset: Past, present, and future. Psychological Services, 3, 195–207.

Lobenstine, F. & Courtney, D. (2013). A case study: The integration of intensive EMDR and ego state therapy to treat comorbid posttraumatic stress disorder, depression, and anxiety. Journal of EMDR Practice & Research, 7, 65-80.

Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing, Second Edition. New York: Guilford Press.

Sheidow, A. J., Jayawardhana, J., Bradford, W. D., Henggeler, S. W., & Shapiro, S. B. (2012). Money matters: Cost-effectiveness of juvenile drug court with and without evidence-based treatments. Journal of Child & Adolescent Substance Abuse, 21, 69-90.

van der Kolk, B. (2007). The developmental impact of childhood trauma. In L. J. Kirmayer, R. Lemelson, & M. Barad (Eds.), Understanding trauma: Integrating biological, clinical, and cultural perspectives, pp. 224-241. New York: Cambridge University Press.

Wesson, M. & Gould, M. (2009). Intervening early with EMDR on military operations: A case study. Journal of EMDR Practice & Research, 3, 91-97.

[This post was updated on 7/7/2015.]



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Posted by Gail on
This confirms what has been happening in our clinic. Patients have improved with EMDR but recently our therapist was told to stop using it. The medical director does not approve of it. It's too bad patients have to suffer because of one person's opinion!
Posted by Ricky Greenwald on
That's unfortunate and very outdated. EMDR is supported by many studies and has been widely recognized as a trauma treatment of choice. We should be featuring effective, efficient treatments, not prohibiting them.
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