De-implementing treatments from the healthcare system: trauma-focused versus non-trauma-focused therapy of post-traumatic stress disorder as an example - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. 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Learn more: PMC Disclaimer | PMC Copyright Notice BMJ Ment Health . 2026 Apr 9;29(1):e302505. doi: 10.1136/bmjment-2026-302505 Search in PMC Search in PubMed View in NLM Catalog Add to search De-implementing treatments from the healthcare system: trauma-focused versus non-trauma-focused therapy of post-traumatic stress disorder as an example Falk Leichsenring Falk Leichsenring 1 Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany 2 Department of Psychosomatics and Psychotherapy, University of Rostock, Rostock, Germany Find articles by Falk Leichsenring 1, 2, ✉ , Barbara Milrod Barbara Milrod 3 Albert Einstein College of Medicine, New York, New York, USA Find articles by Barbara Milrod 3 , Patrick Luyten Patrick Luyten 4 Faculty of Psychology and Educational Sciences, University of Leuven, Leuven, Belgium 5 Research Department of Clinical, Educational and Health Psychology, University College London, London, UK Find articles by Patrick Luyten 4, 5 Author information Article notes Copyright and License information 1 Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany 2 Department of Psychosomatics and Psychotherapy, University of Rostock, Rostock, Germany 3 Albert Einstein College of Medicine, New York, New York, USA 4 Faculty of Psychology and Educational Sciences, University of Leuven, Leuven, Belgium 5 Research Department of Clinical, Educational and Health Psychology, University College London, London, UK ✉ Dr Falk Leichsenring, Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany; [email protected] No, there are no competing interests. Received 2026 Jan 13; Accepted 2026 Mar 19; Collection date 2026. Copyright © Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. Published by BMJ Group. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: https://creativecommons.org/licenses/by-nc/4.0/ . PMC Copyright notice PMCID: PMC13084964 PMID: 41956703 Abstract Recently, a proposal was made to de-implement ineffective or harmful psychotherapeutic treatments from the healthcare system. Given the potential wide-ranging implications of this proposal, a critical review is warranted. As an example of an ‘implementation failure’, the authors of the proposal discussed non-trauma-focused treatments of post-traumatic stress disorder (PTSD). For this reason, we reviewed the evidence for non-trauma-focused psychotherapies compared with trauma-focused or exposure-based psychotherapies of PTSD in adults, published in the recent 7 years. We focused on efficacy and safety as the central criteria for potential (de-)implementation. The majority of meta-analytical results showed non-trauma-focused psychotherapies to be non-inferior to trauma-focused psychotherapies. In only a few analyses, non-inferiority was not found or exposure therapy achieved statistically significantly better effect sizes, which, however, were small and not clinically significant. Furthermore, non-trauma-focused psychotherapies were found to be safe and well-tolerated with low dropout. Hence, key criteria for de-implementation are not met. The results question the claim that non-trauma-focused therapies constitute an implementation failure. Thus, the example of trauma-focused versus non-trauma-focused psychotherapy of PTSD highlights fundamental problems associated with the proposal to de-implement specific treatments from the healthcare system. The reviewed results suggest that researcher allegiance may have an important impact on (de-)implementation decisions and needs to be rigidly controlled for. Several open questions remain, including consented criteria on which de-implementation decisions would be based, who decides about the actors responsible for making these decisions and, crucially, the mechanisms by which those in positions of authority are held accountable. Keywords: Psychotherapy Introduction The efficacy of psychotherapy is a subject of controversial discussion, with researcher allegiance significantly affecting results. 1 , 4 Recently, Herzog and McLean suggested a programme for systematically de-implementing psychotherapeutic treatments that are ineffective or even harmful from the healthcare system. 5 This programme includes seven steps, starting with identifying and prioritising ‘low-value practices’, assessing current use of ‘low-values practices’, adapting knowledge to local context, assessing barriers and facilitators to de-adoption, selecting, tailoring and implementing de-adoption interventions, evaluating de-adoption process and outcomes, and finally sustaining de-adoption. 5 As an example of an implementation failure, Herzog and McLean highlighted the treatment of post-traumatic stress disorder (PTSD). 5 Referring to data of the German healthcare system, Herzog and McLean criticised that the majority of patients with PTSD treated with cognitive–behavioural therapy (CBT) (53%) did not receive trauma-focused CBT, based on the claim that non-trauma focused CBT or non-trauma focused psychotherapies in general are less well supported than trauma-focused treatments. 5 6 Herzog and McLean concluded that the gap between guideline recommendations for PTSD and clinical practice ‘comes at a cost for the society and the individual’. 5 While Herzog and McLean did not explicitly propose to de-implement non-trauma-focused therapies for PTSD, their use of non-trauma-focused therapies as a prominent example for an ‘implementation failure’ 5 seems to implicitly suggest considering non-trauma-focused therapies as candidates for de-implementation. While we concur that ineffective and harmful treatments should not be used, for example critical incident stress debriefing in PTSD listed by Herzog and McLean as ‘expressly harmful’, 5 de-implementing specific treatments from the healthcare system is a complex matter that demands unbiased approaches. Referring to the treatment of PTSD highlighted by Herzog and McLean, we will discuss fundamental problems of the proposed de-implementation programme. For this purpose, we reviewed the evidence for trauma-focused versus non-trauma-focused treatments of PTSD. In addition, we formulated preliminary criteria for de-implementation decisions. Methods Search: We searched in MEDLINE, PsycInfo and the Cochrane library for meta-analyses of randomised controlled trials (RCTs) published in the recent 7 years comparing trauma-focused and non-trauma-focused psychotherapies of PTSD in adults, putting a focus on efficacy and safety. For eligibility, non-trauma-focused therapies were required to represent active psychotherapies, excluding interventions designed as mere controls (eg, psychoeducation or relaxation). In the case of overlap between meta-analyses, we included those meta-analyses that encompassed the largest number of studies for the respective research question. Preliminary criteria for de-implementation: For reviewing the status of non-trauma-focused psychotherapies for PTSD, we are making some preliminary proposals for minimum criteria of de-implementation. A treatment may be considered as (1) Ineffective, if it consistently proves to be not efficacious with regard to the primary outcome in rigorous and unbiased RCTs, showing, for example, that it is less efficacious than placebo. (2) Harmful, if it is consistently associated with significantly more adverse events than comparable treatments. (3) Low tolerability, if its dropout rates are consistently higher than those of comparable treatments. We suggest regarding the criteria 1 and/or 2 as necessary conditions for de-implementing treatments. Additional social, cultural and cost factors may play a role in de-implementation decisions. 7 Results Six meta-analyses that addressed the comparison of trauma-focused versus non-trauma-focused psychotherapies were eligible ( table 1 ). In the following, we will discuss their results with regard to the efficacy and safety of non-trauma-focused psychotherapies for PTSD. Table 1. Meta-analyses comparing non-trauma-focused therapies of PTSD with exposure therapies or trauma-focused therapies. Authors Time of assessment Measures MD (95% CI) MD clinically significant? * † SMD (95% CI) SMD clinically significant? * † Number of studies Number of patients McLean et al 6 ‡ Post (PTSD severity) § 0.30 (0.16 to 0.44) No 35 § Post (low risk of bias) (PTSD severity) § 0.25 (0.10 to 0.41) No 21 § Follow-up (PTSD severity) § 0.41 (0.23 to 0.58) No for CAPS-IV, unclear for PCL 23 § McLean et al 9 ‡ Post (PTSD severity) § 0.34 (0.11 to 0.56) No for CAPS-IV 9 § Hoppen et al 10 ¶ Post CAPS-IV 0.17 (0.03 to 0.31) No § § Post (low risk of bias) CAPS-IV 0.12 (−0.11 to 0.35) No § § <5 MFU CAPS-IV 0.23 (0.06 to 0.40) No § § >5 MFU CAPS-IV 0.20 (0.04 to 0.35) No § § Belsher et al 11 ** Post CAPS-IV 6.83 (1.90 to 11.76) Yes 6 607 Post Different clinician administered measures 0.32 (0.08 to 0.56) No 9 1129 6 MFU CAPS-IV 1.59 (−0.46 to 3.63) No 6 906 12 MFU CAPS-IV 1.22 (−2.17 to 4.61) No 3 485 6 MFU Different clinician administered measures 0.17 (0.05 to 0.29) No 9 1339 9MFU Different clinician administered measures 0.17 (0.03 to 0.31) No 5 728 Post Self-report (PCL) 4.50 (3.09 to 5.90) No 7 983 6 MFU Self-report (PCL) 3.44 (1.86 to 5.02) No 8 1181 12 MFU Self-report (PCL) 1.60 (−0.17 to 3.37) No 5 791 Open in a new tab * CAPS-IV MCID: raw scores: 7.4–13.3 with a midpoint of 10.4, SMD: 0.59–0.94. 12 † PCL MCID: raw scores: 5.7–10.2 with a midpoint of 7.9, SMD: 0.51–0.71. 12 ‡ McLean et al : exposure versus non-trauma-focused therapies. McLean et al used a very narrow definition of trauma-focused therapies, classifying treatments such as interpersonal therapy and psychodynamic therapy as non-trauma-focused. 9 These treatments, however, focus on affective and interpersonal regulation and conflicts associated with the trauma. § Not reported. ¶ Hoppen et al : trauma-focused CBT versus non-trauma-focused therapies. ** Belsher et al : present-centred therapy versus trauma-focused therapies. CAPS, Clinician-Administered PTSD Scale; CBT, cognitive–behavioural therapy; MCID, minimal clinically important difference; MFU, months follow-up; PCL, PTSD Symptom Checklist; PTSD, post-traumatic stress disorder; SMD, standardised mean difference. For confirming their claim that non-trauma-focused treatments are less well supported than trauma-focused treatments, 5 Herzog and McLean referred to a meta-analysis by McLean et al. 6 However, this meta-analysis compared exposure therapies with trauma-focused and non-trauma-focused therapies. Thus, it does not allow for conclusions about trauma-focused versus non-trauma-focused therapies in general. Moreover, while it is true that in this meta-analysis exposure therapy achieved a statistically significantly better outcome in PTSD than non-trauma-focused treatments post-therapy, the difference in terms of a between-group effect size was small (g=0.30, 95% CI 0.16 to 0.44) and even smaller after controlling for risk of bias (g=0.25, 95% CI 0.099 to 0.407). 6 In box 1 , data for minimal clinically important differences (MCIDs) for PTSD are presented. These data clearly indicate that the differences of g=0.30 (95% CI 0.16 to 0.44) or g=0.25 (95% CI 0.099 to 0.407) reported by McLean et al are not clinically important since their upper limits are below the MCIDs (all CI upper limits <0. 59 for Clinician Administered PTSD Scale (CAPS-IV) or <0.51 for PTSD Symptom Checklist (PCL)). 8 This was true for the follow-up assessments, as well ( table 1 ). For the MCID of the PCL, results are not fully clear (0.58 vs 0.51–0.71). For follow-ups, McMean et al unfortunately did not report effect sizes of low risk of bias studies which may again be smaller. In a military population with PTSD, the between-group effect size of exposure versus non-trauma-focused psychotherapies did not exceed the threshold for clinical significance, either (0.56<0.59, table 1 ). 9 This was true for a meta-analysis comparing trauma-focused CBT with non-trauma-focused psychotherapies (0.31<0.59, table 1 ). 10 In another meta-analysis, non-trauma-focused present-centred therapy (PCT) was superior to controls with a large effect size (standardised mean difference (SMD)=0.89, 95% CI 0.59 to 1.1) 11 showing efficacy of PCT. For the raw score difference in CAPS-IV, non-inferiority of PCT to trauma-focused CBT in clinician-rated PTSD severity post-therapy was not confirmed (11.76>10.4, table 1 ). 11 However, when including additional studies using different clinician-administered PTSD assessment, the upper limit of the between-group effect size did not exceed the threshold of clinical significance (0.56<0.59, table 1 ). 12 Thus, in this analysis, PCT was non-inferior to trauma-focused therapies. This was also true for clinician-rated measures in the 6-month and 12-month follow-ups, both for the CAPS-IV raw scores and the SMDs (3.63<7.4, 4.61<7.4, 0.29<0.59, table 1 ). 11 Additionally, in self-report measures of PTSD symptom severity, non-inferiority of PCT was confirmed both post-therapy and in follow-ups (5.9<7.9, 5.02<5.9, 3.37<7.9, table 1 ). 11 Furthermore, as noted by Belsher et al all of the included studies were primarily designed to test the efficacy of trauma-focused CBT which may have biased results against demonstrating the non-inferiority of PCT. 11 The most recent meta-analysis in this area did not find significant difference in PTSD symptoms or adverse events between PCT and trauma-focused therapies, either. 13 After removing outliers, this was also true for depressive symptoms. 13 In addition, no significant differences were found between trauma-focused therapies with versus without exposure on PTSD symptom severity at the end of treatment (SMD=0.02, 95% CI −0.11 to 0.15, p=0.75, I 2 =64%, 29 RCTs, n=3507). 13 With regard to response rates, a recent meta-analysis reported rates in PTSD of 35%, 36% and 35% for trauma-focused CBT, exposure and non-trauma-focused CBT, 14 respectively, again suggesting no differences in efficacy between non-trauma-focused and trauma-focused treatments. Also, these results indicate that the majority of patients with PTSD studied with these interventions are not experiencing sufficient improvement. Box 1. MCIDs for measures of PTSD. For minimal clinical improvements or differences (MCIDs) in PTSD proposals for the most commonly used diagnostic instruments have been made. In the Clinician-Administered PTSD Scale, an MCID was found to correspond to SMDs between 0.59–0.94 or raw scores between 7.4–13.3, with a midpoint of 10.4. 12 In the PTSD Symptom Checklist, minimal clinical improvement corresponds to SMDs between 0.51–0.71 or raw scores between 5.7–10.2, with a midpoint of 7.9. 12 An effect size can be regarded as definitely clinically unimportant if the upper limit of its 95% CI is smaller than the MCID. 8 MCID, minimal clinically important difference; PTSD, post-traumatic stress disorder; SMDs, standardised mean differences. Consistent with the results reported above, a review by Shea et al reported that the majority of studies failed to show a significant difference in efficacy between trauma-focused and non-trauma focused therapies for PTSD. 15 Importantly, with regard to safety and tolerability, meta-analyses reported significantly higher drop-out rates for exposure-based CBT treatments than for PCT, indicating lower tolerability of exposure-based therapies. 11 13 16 Summary of results Non-trauma-focused therapies were found to be superior to controls with large effect sizes, demonstrating efficacy. 11 In addition, the majority of results suggest that non-trauma-focused therapies are not inferior to trauma-focused treatments including exposure therapies. 69 , 11 13 14 16 Non-trauma-focused therapies were neither found to be ineffective nor ‘potentially harmful therapies’. 5 Thus, the claim that non-trauma-focused therapies represent an ‘implementation failure’ is not warranted. Notably, Herzog and McLean did not provide any evidence for their assertion that the gap between guideline recommendations for PTSD and clinical practice ‘comes at a cost for the society and the individual’. 5 A dangerous assertion that comes at a time when mounting evidence exists supporting efficacy and non-inferiority of non-trauma-focused therapies for PTSD. The references Herzog and McLean gave in this context are non-specific and do not address the costs of trauma-focused versus non-trauma-focused therapies, including the well-documented high dropout rates and low uptake of exposure-focused psychotherapies for PTSD. 16 The use of non-trauma-focused treatments for PTSD in clinical practice does not seem to be primarily based on ‘myths’ (eg, ‘stabilisation is always necessary before trauma-focused treatment’) or ‘misconceptions’ (eg, ‘exposure therapy works poorly with complex cases’) as claimed by Herzog and McLean, 5 but is consistent with empirical evidence. Different approaches seem to be effective for the treatment of PTSD, and different patients may benefit from different approaches. Currently, our understanding of what ‘works for whom’ is still relatively limited. Conclusions The discussion of treatments for PTSD as an ‘implementation failure’ 5 highlights fundamental problems associated with the proposal of de-implementing ‘ineffective’ or ‘harmful’ treatments from the healthcare system. It particularly suggests that there is a considerable risk of biased judgements in reviewing evidence to determine efficacy and safety of therapeutic treatments. McLean and Herzog, for example, appear to conflate ‘expressly harmful’ therapies (eg, critical incident stress debriefing) and those that—according to their view—show ‘less robust supportive evidence’. 5 Furthermore, several unresolved issues remain, including a consensus about criteria by which treatments are classified as ineffective or harmful, who determines these criteria, who decides about those persons responsible for making these determinations and the evidence base on which such decisions rest. Herzog and McLean proposed a consortium of stakeholders to make these decisions, including researchers and practitioners, health economists, (de)implementation scientists, patient advocacy groups, funders (eg, health insurance) and policymakers. 5 However, as discussions within guideline committees have often demonstrated, such decisions are frequently influenced by power dynamics rather than by evidence. The American Psychological Association guideline for PTSD serves as a pertinent example. 17 , 19 Ultimately, the question remains about who holds those in control accountable. In particular, researcher allegiance needs to be controlled for by including proponents of rival approaches in a balanced way (adversarial collaboration) 20 to avoid decisions that are rather based on bias than on evidence. 4 These problems need to be adequately addressed before serious consideration of treatment de-implementation. Without this basic equipoise, the door to bias and arbitrariness will be opened. Footnotes Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Patient consent for publication: Not applicable. Ethics approval: Not applicable. Provenance and peer review: Not commissioned; externally peer reviewed. References 1. Wampold BE, Flückiger C, Del Re AC, et al. 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