The Economic Value Of Intensive Trauma Therapy

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

Psychotherapy often 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 of the trauma is not needed.

A recent meta-analyses found eye movement desensitization and reprocessing (EMDR; Shapiro, 2001) to be more more cost-effective (that is, more efficient) than the other well-established trauma treatments (Mavranezouli et al, 2020).  Progressive counting (PC; Greenwald, 2013) is a newer trauma therapy that has been found to be about as effective, efficient, and well tolerated as EMDR (Greenwald & Camden, 2022; Greenwald, McClintock, & Bailey, 2013; 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 et al, 2020). The economy is compelling: even compared to other trauma therapy, the intensive format reduces total number of treatment hours, 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.

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 that the results were achieved much more quickly in the intensive format (Ehlers et al, 2014). Equivalent outcomes were also found for a non-randomized comparison of intensive to weekly EMDR for veterans with PTSD (Hurley, 2018). Other studies of intensive trauma-focused therapy featuring EMDR and prolonged exposure (Van Woudenberg et al, 2018) or EMDR and PC (Greenwald et al, 2020; Greenwald & Camden, 2022) have also shown good outcomes. When done properly, it works.

The bottom line: trauma costs; healing saves; and quick, efficient, effective healing saves the most. Intensive trauma therapy can be a high quality treatment as well as 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., 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.

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

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

Greenwald, R., & Camden, A. A. (2022). A pragmatic randomized comparison of intensive trauma-focused EMDR and PC with victims of crime. Psychological Trauma: Theory, Research, Practice, and Policy.

Greenwald, R., Camden, A. A., Gamache, N., Lasser, K. A., Chapman, R., & Rattner, B. (2020). Intensive trauma-focused therapy with victims of crime. European Journal of Trauma & Dissociation.

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.

Hurley, E. C. (2018). Effective treatment of veterans with PTSD: Comparison between intensive daily and weekly EMDR approaches. Frontiers In Psychology, 9, 1458.

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

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.

Van Woudenberg, C., Voorendonk, E. M., Bongaerts, H., Zoet, H. A., Verhagen, M., Lee, C. W., van Minnen, A. & de Jongh, A. (2018). Effectiveness of an intensive treatment programme combining prolonged exposure and eye movement desensitization and reprocessing for severe post-traumatic stress disorder. European Journal of Psychotraumatology, 9(1), Article 1487225. http://dx.doi.org/10.1080/20008198.2018.1487225

[This post was updated on 12/22/2022.]