Trauma & recovery

Do the Gains Last?

A treatment that works for as long as you are in it is not much of a treatment. Here is what the follow-up data show.

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The right question to ask

Most treatment studies report how people are doing at the end of the protocol. That is the easiest thing to measure and the least interesting thing to know. The question that matters to someone deciding whether to start is whether they will still be better in a year, without still being in therapy.

What the follow-up evidence shows

Kline and colleagues (2018) conducted a meta-analysis of randomised controlled trials specifically to examine long-term outcomes of psychotherapy for PTSD. Treatment gains were largely maintained over follow-up periods, rather than eroding once sessions stopped, and trauma-focused treatments retained their advantage over control conditions at follow-up.

This is consistent with what individual trials had reported. In the Resick and colleagues (2002) comparison of cognitive processing therapy and prolonged exposure, improvements in both active treatments were maintained at follow-up rather than fading after termination.

The broader Cochrane review of psychological therapies for chronic PTSD reached a similar overall conclusion, finding trauma-focused treatments effective and more so than non-trauma-focused approaches, though the authors were explicit that the quality of the evidence base varied considerably across comparisons (Bisson et al., 2013).

Why durability makes sense here

There is a mechanistic reason to expect these gains to hold rather than to require maintenance. Trauma-focused treatments are not managing a symptom in the way that ongoing medication manages blood pressure. They are changing something structural: the fear structure is updated with information that contradicts it, or the beliefs that produced the sense of current threat are revised.

Once a belief has genuinely changed, it does not need to be re-changed weekly. The learning is the outcome, not a side effect of attendance.

The honest qualifications

Three things should be said alongside this.

• Averages describe groups. A meta-analysis showing maintained gains does not promise that any particular person will hold theirs.
• Not everyone responds in the first place, and the follow-up data are about people who did.
• Life continues after treatment ends. New events can reactivate old material, and needing to come back is not evidence that the first course failed.

What the evidence supports is a modest and useful claim: for people who respond, the response tends to be durable, and the goal of finishing therapy and staying finished is a realistic one rather than an optimistic story.

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