A Randomized Controlled Trial of Cognitive–Behavioral Treatment for
Posttraumatic Stress Disorder in Severe Mental Illness
Kim T. Mueser, Stanley D. Rosenberg, Haiyi Xie,
M. Kay Jankowski, Elisa E. Bolton, and Weili Lu
Dartmouth Medical School and Dartmouth Psychiatric Research
Jessica L. Hamblen
Dartmouth Medical School and National Center for
Posttraumatic Stress Disorder
Harriet J. Rosenberg, Gregory J. McHugo, and Rosemarie Wolfe
Dartmouth Medical School and Dartmouth Psychiatric Research Center
A cognitive–behavioral therapy (CBT) program for posttraumatic stress disorder (PTSD) was developed
to address its high prevalence in persons with severe mental illness receiving treatment at community
mental health centers. CBT was compared with treatment as usual (TAU) in a randomized controlled trial
with 108 clients with PTSD and either major mood disorder (85%) or schizophrenia or schizoaffective
disorder (15%), of whom 25% also had borderline personality disorder. Eighty-one percent of clients
assigned to CBT participated in the program. Intent-to-treat analyses showed that CBT clients improved
significantly more than did clients in TAU at blinded posttreatment and 3- and 6-month follow-up
assessments in PTSD symptoms, other symptoms, perceived health, negative trauma-related beliefs,
knowledge about PTSD, and case manager working alliance. The effects of CBT on PTSD were strongest
in clients with severe PTSD. Homework completion in CBT predicted greater reductions in symptoms.
Changes in trauma-related beliefs in CBT mediated improvements in PTSD. The findings suggest that
clients with severe mental illness and PTSD can benefit from CBT, despite severe symptoms, suicidal
thinking, psychosis, and vulnerability to hospitalizations.
Keywords: posttraumatic stress disorder, severe mental illness, cognitive–behavioral therapy, mood
People with severe mental illnesses such as schizophrenia, bipolar
disorder, and treatment-refractory major depression are more likely to
have experienced adverse events in childhood, such as sexual and
physical abuse, and to be victimized in adulthood compared with the
general population (Bebbington et al., 2004; Goodman, Rosenberg,
Mueser, & Drake, 1997; Shevlin, Dorahy, & Adamson, 2007). As a
presumed result of this high vulnerability to trauma, rates of current
posttraumatic stress disorder (PTSD) ranging between 29% and 48%
with prolonged and severe mental illness (Calhoun et al., 2007;
Cascardi, Mueser, DeGiralomo, & Murrin, 1996; Craine, Henson,
Colliver, & MacLean, 1988; Howgego et al., 2005; Mueser et al.,
1998, 2001; Mueser, Salyers, et al., 2004; Switzer et al., 1999). These
rates far exceed the prevalence of PTSD in the general population,
estimated to be 3.5% over 12 months (Kessler, Chiu, Demler, &
Walters, 2005) and 7%–12% over the lifetime (Breslau, Davis, An-
dreski, & Peterson, 1991; Breslau, Peterson, Poisson, Schultz, &
Lucia, 2004; Kessler, Bergland, et al., 2005; Kessler, Sonnega, Bro-
met, Hughes, & Nelson, 1995; Resnick, Kilpatrick, Dansky, Saun-
ders, & Best, 1993).
Those with severe mental illness may experience psychotic
distortions or delusions with themes involving sexual or physical
Kim T. Mueser, Departments of Psychiatry and Community and Family
Medicine, Dartmouth Medical School; Dartmouth Psychiatric Research
Center, Concord, New Hampshire. Stanley D. Rosenberg, M. Kay
Jankowski, Elisa E. Bolton, Weili Lu, Harriet J. Rosenberg, and Rosemarie
Wolfe, Department of Psychiatry, Dartmouth Medical School; Dartmouth
Psychiatric Research Center. Haiyi Xie and Gregory J. McHugo, Depart-
ment of Community and Family Medicine, Dartmouth Medical School;
Dartmouth Psychiatric Research Center. Jessica L. Hamblen, Department
of Psychiatry, Dartmouth Medical School; National Center for Posttrau-
matic Stress Disorder, Boston.
Elisa E. Bolton is currently at the National Center for Posttraumatic
Stress Disorder and the Behavioral Science Division of the Boston Depart-
ment of Veterans Affairs Medical Center, Boston. Weili Lu is currently at
the Department of Psychiatric Rehabilitation and Counseling Professions,
School of Health Related Professions, University of Medicine and Den-
tistry of New Jersey.
None of the authors or their immediate families have a significant
financial arrangement or affiliation with any product or services used or
discussed in this article, nor any potential bias against another product or
This study was funded by Grant MH064662 from the National
Institute of Mental Health. Portions of this research were presented at
the New Annual Conference of the British Psychological Society,
Cardiff, Wales, in March 2006. We appreciate the help of the following
persons in completing this project: Robin Boynton, Lindy Fox, Katie
McDonald, and Susan R. McGurk. We thank David M. Clark, Anke
Ehlers, Shirley Glynn, Robert Hamer, and Paula Schnurr for comments
on earlier drafts of this article.
Correspondence concerning this article should be addressed to Kim T.
Mueser, Dartmouth Psychiatric Research Center, Main Building, 105 Pleasant
Street, Concord, NH 03301. E-mail: firstname.lastname@example.org
Journal of Consulting and Clinical Psychology
2008, Vol. 76, No. 2, 259–271
Copyright 2008 by the American Psychological Association
abuse (Coverdale & Grunebaum, 1998), raising questions about
the reliability and validity of self-reports of trauma and PTSD in
this population. However, research addressing this question sup-
ports the validity of self-reports (Read, van Os, Morrison, & Ross,
2005). Self-reports of trauma in clients with severe mental illness
are reliable over time (Goodman et al., 1999; Meyer, Muenzen-
maier, Cancienne, & Struening, 1996; Mueser et al., 2001), have
been reported to have high rates of external corroboration (Herman
& Schatzow, 1987; Read, Agar, Argyle, & Aderhold, 2003), and
are more likely to be underreported than overreported (Briere &
Zaidi, 1989; Read, 1997). In addition, standardized measures of
PTSD for the general population have been shown to have high
internal and test–retest reliability in people with severe mental
illness (Goodman et al., 1999; Mueser et al., 2001). Finally, the
relationship between trauma characteristics and PTSD does not
appear to be affected by the presence of psychosis, with severity of
trauma exposure and childhood sexual abuse most strongly pre-
dictive of PTSD in both people with severe mental illness (Mueser
et al., 1998; Mueser, Salyers, et al., 2004) and the general popu-
lation (Astin, Ogland-Hand, Coleman, & Foy, 1995; King, King,
Foy, & Gudanowski, 1996; Rodriguez, Ryan, Van De Kemp, &
PTSD in clients with severe mental illness is associated with
more severe symptoms, worse functioning, and more frequent
hospitalizations (Mueser, Essock, Haines, Wolfe, & Xie, 2004;
Switzer et al., 1999). These findings have led to the hypothesis that
PTSD may interact with severe mental illness, through both the
direct effects of PTSD symptoms, such as overarousal exacerbat-
ing other psychiatric symptoms, and indirect effects, such as
problems with interpersonal trust leading to a poor working alli-
ance with the case manager and receipt of fewer illness manage-
ment services (Mueser, Rosenberg, Goodman, & Trumbetta,
2002). Because of the high prevalence of PTSD in this population
and its association with a worse course of illness, attention has
turned to implementing routine screening of trauma and PTSD in
community mental health center settings (Cusack, Frueh, & Brady,
2004; Eilenberg, Fullilove, Goldman, & Mellman, 1996), explor-
ing obstacles to such assessment (Frueh et al., 2002; Salyers,
Evans, Bond, & Meyer, 2004), and developing treatments to
address this problem (Frueh, Cusack, Grubaugh, Sauvageot, &
Wells, 2006; Rosenberg et al., 2001).
Cognitive–behavioral therapy (CBT) is an effective treatment
for PTSD (Bradley, Greene, Russ, Dutra, & Westen, 2005). How-
ever, research on CBT for PTSD has mainly focused on people in
the general or veteran population who either are seeking help or
are referred to treatment related to specific traumatic experiences
(e.g., combat, rape, childhood sexual abuse, auto accidents, disas-
ter/terrorist attacks). These individuals differ from those with
severe mental illness who are already in treatment for another
psychiatric disorder (e.g., at community mental health centers),
who are not usually seeking treatment for their traumatic experi-
ences, and whose chronic PTSD has gone unrecognized despite
years of mental health treatment (Craine et al., 1988; Mueser et al.,
1998; Switzer et al., 1999).
Individuals with severe mental illness present several challenges
to treatment. Clinically, common symptoms such as suicidal ide-
ation, self-injurious behavior, psychosis, and mood swings can
often be only tenuously stabilized, and exacerbations may require
hospitalization, rendering it difficult to provide consistent therapy
(Corrigan, Mueser, Bond, Drake, & Solomon, 2008). Furthermore,
persistent symptoms often lead to functional impairments in self-
care and the ability to work, culminating in permanent disability
(Waghorn, Chant, White, & Whiteford, 2004). The net result is
that clients often have poor housing, lack economic resources and
social support, and live chronically unstable lifestyles prone to
frequent crises. Treatment programs for PTSD in clients with
severe mental illness must accommodate to the high vulnerability
and special needs of these individuals.
An additional consideration is the heterogeneity of this popula-
tion. Although people with severe mental illness represent several
different diagnostic groups—most frequently schizophrenia and
mood disorders—they often share many important clinical and
social characteristics, such as high levels of distress, poor func-
tioning, and poverty (Corrigan et al., 2008). As a result of their
disability, many such individuals receive entitlements (e.g., Social
Security disability income) and are served in the public community
mental health system by multidisciplinary treatment teams that
employ the same psychosocial interventions to treat specific prob-
lems areas (e.g., vocational rehabilitation, substance abuse, hous-
ing supports, symptom management), regardless of clients’ psy-
chiatric diagnoses. Thus, there is a pragmatic need for treatments
that are sufficiently flexible to be effective across a variety of
different psychiatric disorders in order to maximize the adoption of
interventions for PTSD at community mental health centers.
Several interventions to address this need have been developed
in recent years—interventions that focus on either the broad array
of trauma sequelae (Harris, 1998) or specifically PTSD (Frueh et
al., 2004; Mueser et al., 2007) in persons with severe mental
illness. To this end, we developed, standardized, and pilot-tested a
12–16 session individual CBT program for PTSD in severe mental
illness (Mueser, Rosenberg, Jankowski, Hamblen, & Descamps,
2004; Rosenberg, Mueser, Jankowski, Salyers, & Acker, 2004).
The program includes breathing retraining, education about the
PTSD, and cognitive restructuring. Both cognitive restructuring
(i.e., identifying and challenging inaccurate trauma-related beliefs
that lead to negative emotions) and exposure therapy (i.e., planned
exposure to feared but safe trauma-related stimuli, such as mem-
ories and situations) have strong empirical support for the treat-
ment of PTSD in the general population (Marks, Lovell,
Noshirvani, Livanou, & Thrasher, 1998; Resick, Nishith, Weaver,
Astin, & Feuer, 2002; Tarrier et al., 1999), with the combination
no more effective than either approach alone (Bryant, Moulds,
Guthrie, Dang, & Nixon, 2003; Foa et al., 2005; Marks et al.,
1998). We chose cognitive restructuring as the primary technique
for treating PTSD for two practical reasons.
First, there is extensive clinical and research experience with the
use of cognitive restructuring for clients with severe mental illness,
including schizophrenia (Turkington, Kingdon, & Weiden, 2006),
severe depression (Hollon, DeRubeis, & Shelton, 2005), and bi-
polar disorder (Lam, Hayward, Watkins, Wright, & Sham, 2005;
Scott et al., 2006), suggesting its feasibility for treating PTSD in
this population. Much less is known about the feasibility of expo-
sure therapy for people with severe mental illness, with only a few
published case studies or noncontrolled trials (Arlow, Moran,
Bermanzohn, Stronger, & Siris, 1997; Hofmann, Bufka, Brady,
DuRand, & Goff, 2000; Mueser & Taylor, 1997; Nishith, Hearst,
Mueser, & Foa, 1995). Second, clients with severe mental illness
are highly sensitive to stress (Butzlaff & Hooley, 1998; Myin-
MUESER ET AL.
Germeys, van Os, Schwartz, Stone, & Delespaul, 2001; Nuechter-
lein & Dawson, 1984), suggesting that cognitive restructuring may
be more acceptable and more readily tolerated than exposure
We report here the results of a controlled evaluation of our CBT
program, which is the first randomized controlled trial to evaluate
an intervention specifically designed to treat PTSD in individuals
with severe mental illness. We compared the CBT for the PTSD
program with TAU and evaluated the following:
Hypothesis 1: CBT will be more effective than TAU at
eliminating PTSD diagnosis, reducing PTSD symptoms and
negative trauma-related cognitions, and improving knowl-
edge of PTSD.
Hypothesis 2: CBT will be more effective than TAU at
reducing depression, anxiety, other psychiatric symptoms,
and health-related concerns.
Hypothesis 3: CBT will be more effective than TAU at
improving the working alliance between the client and case
We also evaluated whether homework completion contributed
to treatment response in the CBT program, based on prior research
linking homework to outcomes in CBT (Kazantzis, Deane, &
Ronan, 2000). Finally, we examined whether changes in negative
trauma-related beliefs mediated improvements in PTSD symptoms
following participation in the program.
A randomized controlled trial was conducted to compare the
CBT for PTSD program with comprehensive mental health TAU
in clients with severe mental illness who were receiving services at
four publicly funded community mental health centers in the
northeastern United States. Assessments were conducted by
blinded interviewers at baseline, following the 4- to 6-month
treatment period for the CBT program, and 3 and 6 months later.
Recruitment for the study began in May 2002, and the last inter-
view was conducted in February 2006.
Inclusion criteria for participation in the study were (a) mini-
mum age 18 years; (b) designation by the states of New Hampshire
or Vermont as having a severe mental illness, defined as a DSM–IV
Axis I disorder and persistent impairment in the areas of work,
school, or ability to care for oneself; (c) DSM–IV diagnosis of
major depression, bipolar disorder, schizoaffective disorder, or
schizophrenia; (d) current DSM–IV diagnosis of PTSD; and (e)
legal ability and willingness to provide informed consent to par-
ticipate in the study. We initially planned to enroll and treat only
clients who met criteria for “severe” PTSD based on the Clinician
Administered PTSD Scale (CAPS; see below), defined by Weath-
ers, Ruscio, and Keane (1999) as a CAPS–Total score greater than
or equal to 65. However, due to lower–than-expected recruitment
rates we modified this criterion to include all clients with PTSD
based on CAPS. For this reason, we conducted separate explor-
atory analyses examining changes in PTSD diagnosis and severity
on the subgroups of clients with severe or mild–moderate PTSD at
Exclusion criteria for participation in the study were (a) psychi-
atric hospitalization or suicide attempt within the past 3 months;
and (b) current DSM–IV substance dependence. All study proce-
dures were approved by the institutional review boards of Dart-
mouth College and the State of New Hampshire.
Axis I psychiatric disorders other than PTSD were assessed with
the Structured Clinical Interview for DSM-IV (SCID–I; First,
Spitzer, Gibbon, & Williams, 1996). Because of the extensive
literature on borderline personality disorder and PTSD (Connor et
al., 2002; Gunderson & Sabo, 1993; McLean & Gallop, 2003), we
evaluated Axis II diagnosis of borderline personality disorder with
the SCID–II (First, Spitzer, Gibbon, Williams, & Benjamin, 1994).
SCID assessments and trauma history were administered only at
baseline, with the remaining assessments repeated at posttreatment
and 3- and 6-month follow-ups. The primary outcome measures
were PTSD severity and diagnosis, and the secondary outcomes
were measures of knowledge about PTSD, trauma-related cogni-
tions, depression, anxiety, perceived health and mental health
functioning, and working alliance with the case manager.
Trauma and PTSD.
History of trauma exposure was evaluated
with the Trauma History Questionnaire (Green, 1996), which was
previously adapted for persons with severe mental illness (Mueser
et al., 1998). PTSD diagnoses and symptom severity were based on
CAPS (Blake et al., 1995), a widely used, semistructured interview
for the assessment of PTSD. For each symptom, a frequency and
intensity rating is provided, with overall severity scores computed
by summing the frequency and intensity scores for all of the PTSD
symptoms (CAPS–Total). Prior research indicates that the CAPS is
a reliable and valid instrument for assessing PTSD in persons with
severe mental illness (Mueser et al., 2001). Information was re-
corded on whether the traumatic event occurred in childhood or
adulthood, but not the specific age or the chronicity of PTSD
Trauma-related cognitions were evaluated with the Posttrau-
matic Cognitions Inventory (Foa, Ehlers, Clark, Tolin, & Orsillo,
1999), a self-report measure of common negative beliefs about
oneself, other people, and the world that frequently occur in
individuals with PTSD. High scores correspond to greater endorse-
ment of negative beliefs. Understanding of PTSD was assessed
with the PTSD Knowledge Test, which contains 15 multiple
choice questions about PTSD. This test has been shown to be
sensitive to the effects of education about PTSD in clients with
severe mental illness (Pratt et al., 2005).
Overall psychiatric symptoms were assessed
with the expanded version of the Brief Psychiatric Rating Scale
(Lukoff, Nuechterlein, & Ventura, 1986), a widely used measure
that taps a broad range of psychiatric symptoms (Shafer, 2005).
Self-reported depression and anxiety were rated with the Beck
Depression Inventory—II (Beck, Steer, & Brown, 1996) and the
Beck Anxiety Inventory (Beck & Steer, 1990). Self-reported men-
tal health and physical functioning were assessed with the Short
Form—12 (Ware, Kosinski, & Keller, 1994), which is reliable and
valid for clients with severe mental illness (Salyers, Bosworth,
Swanson, Lamb-Pagone, & Osher, 2000).
CBT FOR PTSD IN SEVERE MENTAL ILLNESS
ager (i.e., not the therapist providing CBT treatment) was rated using
the client version of the Working Alliance Inventory (Horvath &
Greenberg, 1989). This measure has been shown to be reliable and
valid for clients with severe mental illness (Stylianos & Goering,
1989), with high scores corresponding to a stronger alliance.
All assessments were conducted by master’s or Ph.D. level
trained clinical interviewers who were blind to treatment assign-
ment. Clients were instructed at the beginning of interviews to not
talk about any treatments for trauma-related problems they may
have received. Interviewers were requested to inform the project
coordinator if the client broke the blind during an interview.
Interviewers were not asked to guess clients’ treatment assign-
ments, to avoid directly encouraging them to formulate hypotheses
about how treatment may have affected clients’ symptoms, which
could have influenced subsequent ratings. No specific instances of
blind breaking were noted in the study. Regular reliability checks
were conducted based on audiotaped interviews, with intraclass
correlation coefficients of .97 for CAPS–Total,.97 for BPRS–
Total, and ? ? .91 for PTSD diagnosis based on CAPS.
The therapeutic alliance with the case man-
All clients were receiving comprehensive treatment for their psy-
chiatric illness at their local community mental health center and
continued to receive these services throughout the study period, re-
gardless of which treatment group they were assigned to. Compre-
hensive mental health treatment at these centers included pharmaco-
logical treatment and monitoring, case management, supportive
counseling, and access to psychiatric rehabilitation programs such as
vocational rehabilitation. No efforts were made to control or modify
any of these services provided to study participants.
CBT for PTSD program.
An outline of the 12- to 16-session
program is provided in Table 1. Sessions followed a structured
format and included handouts, worksheets, and homework assign-
ments. The content of each session was summarized by therapists
using a standardized contact sheet, which was also used to record
whether homework was completed (not completed, partially com-
pleted, or completed). All sessions were conducted at clients’ local
community mental health center, with regular contact and coordi-
nation between the CBT therapist and the treatment teams provid-
ing comprehensive mental health treatment. CBT was provided by
Overview of Cognitive–Behavioral Therapy Program for PTSD
1 IntroductionEngage client in program
Provide treatment overview
2 Crisis Plan Review Decide on a crisis plan with client
Clarify with client’s treatment team plan for managing any crises
3 Psychoeducation: Part I. Core
Symptoms of PTSD
Help client understand the nature of PTSD
Make information relevant to client’s own experience of symptoms
4 Breathing Retraining Improve client’s ability to manage tension and anxiety associated with PTSD1?
5 Psychoeducation: Part II.
Associated Symptoms of
Help client understand how other problems and symptoms are related to PTSD and
6 Cognitive Restructuring: Part I.
Common Styles of Thinking
Establish relationship between thoughts and feelings
Discuss role of life experiences, including trauma, in causing thoughts and beliefs
Teach client how to recognize common but incorrect thinking patterns that lead to
7 Cognitive Restructuring: Part II.
The Five Steps of Cognitive
Teach client step-by-step process for using cognitive restructuring when distressed:
a. Describe situation
b. Identify strongest feeling
c. Identify thought underlying feeling
d. Challenge thought
e. Take action by either changing thought or making a plan to deal with the
Help client first practice using cognitive restructuring to deal with distressing
Then help client use cognitive restructuring to deal with trauma-related thoughts
8 Generalization Training and
Bring treatment to closure
Conduct session where client explains cognitive restructuring to case manager
Ease transition from PTSD treatment to care as usual with treatment team
PTSD ? posttraumatic stress disorder.
MUESER ET AL.
seven clinicians (five women and two men, six with a Ph.D. and
one with a master’s). Weekly supervision was provided. Fifteen
percent of all sessions were randomly selected for fidelity moni-
toring using a standardized scale. Treatment exposure was defined
a priori as completion of at least six sessions so as to ensure that
there would be at least three sessions of cognitive restructuring, the
presumed critical ingredient in the program (Rosenberg et al.,
Clients assigned to TAU continued to receive the usual
services they had been receiving before enrollment in the program.
None of the mental health centers offered either cognitive restruc-
turing or exposure therapy treatments for PTSD, although support-
ive counseling for trauma-related problems was available.
Recruitment of study clients was conducted by providing ori-
entation meetings to case managers and clinical staff at the com-
munity mental health centers. At these meetings, the purposes and
methods of the study were described, and clinical instruments for
screening potentially eligible clients were provided. Clinicians
then discussed the project with their clients who met screening
eligibility criteria, and referred interested clients to a member of
the research team. A research staff member reviewed the study
procedures, obtained written informed consent, and scheduled the
baseline interview, which was also used to confirm eligibility for
the study. Clients who completed the baseline interview were then
randomized to the CBT program or TAU. Clients who were
randomized to CBT were also scheduled for an additional assess-
ment session to evaluate their neurocognitive functioning. The
results of these assessments will be reported elsewhere.
Randomization was conducted at a central location in the re-
search center by a computer-based randomization program, with
assignments not known in advance by either clinical or research
staff. When a client had completed the baseline assessment and his
or her eligibility for the study was confirmed, the interviewer
called the research center and a member of the research team
obtained the randomized assignment from the computer. The client
was informed about the assignment by the project coordinator.
Randomization to treatment groups was stratified by site and by
the following three diagnostic groups: major mood disorder with-
out borderline personality disorder (N ? 64), major mood disorder
and borderline personality disorder (N ? 27), and schizophrenia or
schizoaffective disorder (N ? 17). In order to minimize large
differences in the number of clients randomized to the two treat-
ments, randomization was conducted in blocks of four within each
of the 12 strata (e.g., schizophrenia or schizoaffective disorder at
site Number 1).
In order to ensure that posttreatment and follow-up assessments
for clients assigned to TAU and CBT occurred at similar time
intervals following the baseline assessment, the dates for follow-up
assessments for clients in TAU were yoked to the follow-up
assessment dates for clients in CBT based on their completion of
the program. Clients were reminded of follow-up assessments
through a combination of phone calls, letters, and contacts with
their case managers. Clients were paid for participating in the
On the basis of prior noncontrolled research with this treatment
model in persons with PTSD and severe mental illness (Rosenberg
et al., 2004) and research on cognitive–behavioral treatment of
PTSD in the general population (Foa, Keane, & Friedman, 2000),
we estimated power to detect a between-group effect size on CAPS
severity of .70 for a two-tailed, independent-groups t test, with
alpha set at .05 (Borenstein, Rothstein, & Cohen, 1997). With an
expected 5%–10% dropout rate from the CBT for PTSD interven-
tion, we planned to randomize 88 clients in order to have com-
pleted data on 80 clients, resulting in power to detect a significant
difference between the treatment groups of .87. Because the rate of
dropout from the CBT for PTSD program exceeded the anticipated
rate, we increased the sample size to 108 in order to maintain the
same level of power to detect differences between groups in PTSD
Two-tailed t tests and ?2analyses were used to compare the
CBT and TAU groups on demographic characteristics, psychiatric
history, and outcome measures at baseline. Prior to statistical
modeling we conducted descriptive statistical analyses and exam-
ined the distributions of each variable for skewness and possible
Intent-to-treat analyses were conducted to determine treatment
effects on the primary outcome measures. Because there were no
significant differences between CBT and TAU on these variables
at baseline, and because there were only three follow-up assess-
ment points, rather than fitting parametric curves with random
effects we elected to include the baseline as a covariate and fit
baseline adjusted mean response profile models (Fitzmaurice,
Laird, & Ware, 2004) using the SAS PROC MIXED procedure for
continuous outcomes (e.g., CAPS–Total) and SAS PROC GEN-
MOD for dichotomous outcomes (e.g., CAPS PTSD diagnosis).
This approach, also referred to as covariance pattern models
(Hedeker & Gibbons, 2006), is similar to a traditional analysis of
covariance except that it can accommodate correlated data by
selecting appropriate covariance structures as well as missing data
with maximum likelihood estimation (Jennrich & Schluchter,
1986). Rather than fitting models for different outcomes with
possibly different covariance structures, we obtained estimates of
standard error in PROC MIXED by using the “empirical” estimate
option. This method is based on “sandwich estimation” (Diggle,
Liang, & Zeger, 2002) and yields robust and asymptotically con-
sistent estimates of variance and covariance regardless of the
data’s actual covariance structure.
For the continuous variables, treatment group (CBT, TAU),
diagnosis (mood disorder without borderline personality disorder,
mood disorder and borderline personality disorder, schizophrenia–
schizoaffective), time, and their interactions were included in the
model, with the baseline score and education level (post–high
school education vs. not) as covariates, and the posttreatment and
3- and 6-month scores as the dependent variables. For the cate-
gorical variable (CAPS PTSD diagnosis), the same model was fit,
except that baseline was not included as a covariate because it was
a constant. Site was also included in the initial analyses but
dropped from the final model because it did not alter the main
group effects. Since the baseline was statistically adjusted, treat-
ment effects were evaluated with group main effects (i.e., differ-
ences in group mean response profiles). In line with this approach,
CBT FOR PTSD IN SEVERE MENTAL ILLNESS
effect sizes were computed based on the last observation available
using Cohen’s d.
We next evaluated whether clients’ follow up on homework
assignments in CBT (i.e., percentage of assignments completed)
influenced their outcomes. For the clients who completed the CBT
for PTSD program, similar mean response profile models as de-
scribed above were fit using PROC MIXED and PROC GEN-
MOD, with the baseline dependent variable included as a covari-
ate, and homework completion (binary coded as high or low based
on a mean split of the sample) and time as independent variables.
The effect for homework is a test of whether homework comple-
tion influences the mean responses at the follow-up assessments.
Last, we examined whether improvements in PTSD symptoms
at posttreatment and 3- and 6-month follow-ups were mediated by
changes in negative trauma-related beliefs using Kenny et al.’s
(2004) approach, which includes (a) showing an effect of the
intervention on the mediator (PTCI), (b) showing an effect of the
intervention on the outcome (CAPS–Total), and (c) showing that
the effect of treatment on the outcome is reduced or eliminated
when the effect of treatment on the mediator is statistically con-
trolled. We did not compute a Sobel test because of the limited
sample size (Baron & Kenny, 1986). These analyses were con-
ducted using mean response profile models, as described above.
A total of 270 clients were referred to the study, of whom 108 met
inclusion criteria, provided consent, and were randomized to CBT or
TAU. Figure 1 shows a flow chart of client recruitment and partici-
pation in the study. The characteristics of the clients assigned to CBT
or TAU are summarized in Table 2. There were no differences
between the groups on any demographic, diagnostic, or baseline
measures or in the rates of follow-up assessments (ps ? .10).
The most common traumatic event due to which clients reported
PTSD was childhood sexual abuse (N ? 37, 34%), followed by
childhood physical abuse (N ? 19, 17%), the sudden unexpected
death of a loved one (N ? 16, 15%), adult sexual assault (N ? 14,
13%), adult physical assault (N ? 12, 11%), other traumatic event
(N ? 4, 4%), sexual and physical assault (N ? 2, 2%), witnessing
violence (N ? 2, 2%), motor vehicle accident (N ? 1, 1%), and
combat (N ? 1, 1%). Among the 54 clients assigned to CBT, 44
(81%) were exposed to six or more treatment sessions and 38
(70%) completed the 12- to 16-session program.
Examination of the distributions of the primary outcome mea-
sures revealed no outliers and indicated approximately normal
distributions. The results of analyses comparing the CBT and TAU
groups are summarized in Table 3. We report means and standard
deviations (or percents for dichotomous variables), F-test results
from the mean response profile models, and between-group effect
sizes. In terms of our primary hypotheses, CBT was not more
effective than TAU at eliminating PTSD diagnosis, but was sig-
nificantly better in reducing PTSD symptoms and negative trauma-
related cognitions, and improving knowledge of PTSD. CBT was
also more effective than TAU at reducing depression, anxiety,
other psychiatric symptoms, and health-related concerns, as well
as improving the working alliance between the client and case
manager. In a post hoc attempt to better understand these results,
we restricted the sample to the original target population: clients
with severe PTSD (CAPS ? 65). In this analysis, effect sizes for
both CAPS–Total and CAPS–Diagnosis increased, from .45 to .59
and from .27 to .40, respectively, whereas for clients with mild–
moderate PTSD (CAPS ? 65) the effect sizes decreased to .12 and
There was only one significant interaction between psychiatric
diagnosis and treatment group, for the SF–12 Physical, F(2, 73) ?
4.83, p ? .01. Post hoc within-diagnostic group analyses indicated
significant treatment effects on the SF–12 Physical for clients with
borderline personality disorder and major mood disorder, F(1,
15) ? 16.61, ?p ? .001, and schizophrenia, F(1, 10) ? 5.24,
?p ? .05, but not for clients with major mood disorder only. For
both diagnostic groups, clients who received CBT improved more
in perceived physical health than did clients who received TAU.
Effect of Homework Completion on Treatment Outcomes
The average rate of homework completion across all sessions
was 50% (range: 0%–92%). Analyses of homework completion
indicated significant effects for CAPS–Total, F(1, 37) ? 5.81, p ?
.02, effect size (ES) ? .93; CAPS–Diagnosis1, F(1) ? 4.71, p ?
.03, ES ? .47; BDI–II, F(1, 37) ? 15.21, p ? .0004, ES ? .97;
BAI, F(1, 37) ? 6.60, p ? .01, ES ? .65; SF–12 Mental Com-
ponent, F(1, 34) ? 6.19, p ? .02, ES ? .68; and PTCI, F(1, 37) ?
6.10, p ? .02, ES ? .44, but not for PTSD Knowledge, SF–12
Physical Component, BPRS–Total, or WAI–Total. Higher rates of
homework completion were associated with greater improvements
in symptoms, perceived mental health, and negative trauma-related
Tarrier, Sommerfield, Pilgrim, and Faragher (2000) have re-
ported that duration to complete therapy and missed appointments
were associated with worse response to CBT for PTSD in the
general population. These problems could reflect lack of engage-
ment and motivation in therapy and might also be associated with
poor follow-through on homework assignments. We did not obtain
information on missed sessions but did on duration of therapy. To
explore whether homework completion was related to duration of
therapy, we computed a Spearman’s rho correlation coefficient in
the subgroup of clients who completed the CBT for PTSD pro-
gram. This correlation was significant (rho ? –.34, N ? 48, p ?
.02), and as expected lower rates of homework completion were
related to a longer time to complete therapy.
The steps of the analysis testing whether changes in negative
trauma-related beliefs (PTCI) mediated improvements in PTSD
symptom severity (CAPS–Total) following CBT are summarized
in Table 4. CBT had a significant effect on trauma-related beliefs
(Step 1) and on PTSD severity (Step 2). Finally, when trauma-
related beliefs was added to the statistical model, the effect of CBT
on PTSD severity was no longer significant, whereas trauma-
related beliefs and PTSD severity were highly significantly related
1CAPS–Diagnosis has only one df because it was analyzed with general
estimating equations analysis.
MUESER ET AL.
(Step 3). The results are consistent with the hypothesis that
changes in trauma-related beliefs over the course of CBT mediated
reductions in PTSD symptom severity.
The setting and client population for this study differed from
those of most prior studies of PTSD. Treatment took place at
several community mental health centers that provided long-
term care to clients with severe mood or schizophrenia-
spectrum disorders, and whose comorbid PTSD had only been
recently identified through screening for the purposes of the
study. Over 90% of the clients had prior psychiatric hospital-
izations, and most were receiving Social Security entitlements
because of their mental illness. In contrast, most other research
in this area has focused on general or veteran population sam-
ples, recruited either by referrals or advertisements for treat-
ment of psychological distress related to traumatic events.
Despite the chronic and disabled nature of this study popula-
tion, clients were successfully engaged in the CBT program,
with a comparable dropout rate (19%) to PTSD treatment
studies in the general population (Bradley et al., 2005). Fur-
thermore, clients in CBT improved significantly more than
those in TAU on PTSD symptoms and a range of other out-
comes. The results suggest that despite the multitude of chal-
lenges faced by clients with severe mental illness and PTSD, CBT
can be effective at reducing the severity of their symptoms.
Although clients assigned to CBT improved more on most out-
comes, those in TAU nevertheless also improved, despite the lack of
CBT treatment for PTSD in usual care. It is possible that the com-
prehensive mental health care available to everyone in this study,
including supportive counseling, afforded some benefit to clients in
TAU for managing trauma-related problems such as PTSD. Alterna-
TAC U BT
Assessed for eligibility
(n = 270)
Not eligible (n = 95)
Not interested (n = 30)
Did not follow through (n = 37)
Allocated to CBT program (n =54)
Never engaged: received 0 sessions (n = 2)
Failed to attend scheduled appointments (n = 2)
Dropped out: received 1-5 sessions of CBT program
(n = 8)
Other life stressors (n = 3)
Other psychiatric symptoms (n = 2)
Conflict with work (n = 2)
Left area (n = 1)
Exposed: received >5 sessions of CBT program (n = 44)
Analyzed at posttreatment (n = 32)
Analyzed at 3 months posttreatment (n = 30)
Analyzed at 6 months posttreatment (n = 33)
(n = 108)
Analyzed at posttreatment (n = 27)
Analyzed at 3 months posttreatment (n = 35)
Analyzed at 6 months posttreatment (n = 20)
Allocated to TAU program (n = 54)
Lost to all follow-up (n = 11) Lost to all follow-up (n = 11)
Flow of participants through the study. TAU ? treatment as usual; CBT ? cognitive–behavioral
CBT FOR PTSD IN SEVERE MENTAL ILLNESS
tively, the severity of PTSD symptoms may covary with other psy-
chiatric symptoms in clients with severe mental illness, resulting in
some clients meeting diagnostic criteria for PTSD intermittently as
symptoms fluctuate over time. In line with this, severe PTSD (based
on CAPS–Total scores ? 65) has been shown to be more stable over
brief periods of time (1–2 weeks) than mild–moderate PTSD (Mueser
et al., 2001). In the present study, clients with severe PTSD benefited
more from the CBT program in terms of PTSD severity and diagnosis
than did those with mild–moderate symptoms. The findings suggest
that the CBT program might better be directed at clients with severe
PTSD, who according to this and one previous study (Mueser et al.,
2001) represent approximately three quarters of clients with severe
mental illness and PTSD.
Clients who received CBT also reported more improvement in
their working alliance with their case manager than did clients in
TAU, as hypothesized. These results could have been due to the
effects of cognitive restructuring on challenging beliefs related to
the pervasive interpersonal distrust often present in clients with
PTSD (American Psychiatric Association, 1994; Carmen, Rieker,
& Mills, 1984; Figley, 1985), leading to improved trust in the case
manager. The working alliance may have also improved because
the therapist providing CBT maintained ongoing contact with the
case manager during the program, and one session focused on
fostering collaboration by having the client explain cognitive re-
structuring to the case manager in order to elicit his or her support
for when the program ended (see Table 1). Therapeutic alliance
with the case manager has been shown to predict outcome in
clients with severe mental illness (Gehrs & Goering, 1994; Neale
& Rosenheck, 1995; Priebe & Gruyters, 1993). The findings
suggest that the CBT program could improve working alliance
with the case manager, which in turn could improve the course of
the psychiatric illness, as hypothesized in our interactive model of
PTSD and severe mental illness (Mueser et al., 2002).
Higher rates of homework completion contributed to better
outcomes in the CBT program, including greater improvements in
PTSD symptoms and diagnosis, posttraumatic cognitions, depres-
sion, anxiety, and perceived mental health functioning, with effect
sizes of .95 for PTSD severity, .97 for depression, and .65 for
anxiety. These effect sizes are considerably higher than those
reported in a meta-analysis of the effects of homework on depres-
sion (.38), anxiety (.27), and other outpatient problems (.40; Ka-
zantzis et al., 2000). The assignment of homework to practice
skills taught in therapy is a central tenet of CBT (Beck, 1995).
Homework completion has previously been reported to be associ-
ated with gains in CBT for depression (Coon & Thompson, 2003;
Startup & Edmonds, 1994), social phobia (Edelman & Chambless,
1995), and agoraphobia (Edelman & Chambless, 1993). To our
knowledge, the effects of homework completion on outcomes of
CBT in either PTSD or severe mental illness have not been
reported. Considering the magnitude of the effect sizes for home-
work, strategies for increasing homework adherence could be an
important approach to maximizing the treatment gains of clients in
the CBT for PTSD program.
The mediation analysis was consistent with the hypothesis that
changes in negative trauma-related beliefs in CBT improved PTSD
symptoms. This finding is consistent with cognitive theories that
posit trauma-related schemas underlie PTSD symptoms (Dal-
gleish, 2004; Ehlers & Clark, 2000; Ehlers, Mayou, & Bryant,
2003). Research on CBT suggests that changes in cognition me-
diate treatment response for depression (Burns & Spangler, 2001;
DeRubeis, Tang, Gelfand, & Freely, 2000), anxiety (Burns &
Spangler, 2001), and panic disorder (Smits, Powers, Cho, & Telch,
2004). Research on PTSD has shown that both cognitive restruc-
turing and exposure therapy result in improvements in negative
trauma-related beliefs (Ehlers, Clark, Hackmann, McManus, &
Baseline Characteristics of the Sample
Variable CBT (n ? 54) TAU (n ? 54)Total (n ? 108)
Education (high school graduate)
Mean age in years (SD)
Borderline personality disorder
Substance use disorder
Prior psychiatric hospitalizationa
Median number of prior hospitalizations (range)
Mean age in years at first hospitalization (SD)
Mean period in months since last hospitalization (SD)
as appropriate. CBT ? cognitive–behavioral therapy; TAU ? treatment as usual.
aData on prior psychiatric hospitalization were missing for 3 clients in CBT and 7 clients in TAU.
Data are given as number (percentage) unless otherwise indicated. No values between two groups were statistically different using ?2test or t test
MUESER ET AL.
Fennell, 2005; Foa & Rauch, 2004; Resick et al., 2002), although
mediation analyses have not been reported.
While the CBT program led to significant improvements in
PTSD and other symptoms, in the overall sample it did not result
in a significantly greater reduction in PTSD diagnosis, and symp-
toms remained in the moderate to severe range at posttreatment
and follow-up for clients who received CBT. For example, in the
total sample 63%–73% of clients who received CBT continued to
meet criteria for PTSD at posttreatment or follow-up compared
with 77%–85% of those in TAU, whereas among clients with
severe PTSD at baseline the respective rates for meeting PTSD
criteria were 68%–78% compared with 88%–92%. The findings
suggest that CBT results in clinically significant improvements for
some clients, but many still experience persistent and severe symp-
toms. Further work is needed to explore whether the CBT for
PTSD model could be modified to make it more effective, such as
by providing additional sessions for clients whose PTSD does not
remit in 12–16 sessions or incorporating exposure therapy into the
The results of other treatment approaches for trauma-related
problems in persons with severe mental illness—such as Harris’s
(1998) broad-based trauma recovery and empowerment group
therapy model and Frueh et al.’s (2004) individual and group
model that combines anxiety reduction methods with exposure
therapy and social skills training—have not been reported. We
have also developed a 21-session group-based CBT program for
clients with severe mental illness that incorporates the major
components of the individual-based program studied here, as well
as several sessions that address coping with persistent symptoms
and developing a personal recovery plan (Mueser et al., 2007).
Noncontrolled research on 41 clients who participated in this
program indicated posttreatment and follow-up PTSD rates for the
CBT group participants of 73%, compared with 88%–100% for
dropouts, suggesting comparable effects to those reported here for
Results of Mean Response Profile Analyses and Effect Sizes With Baseline and Education as Covariates for Primary Outcomes
OutcomeConditionBase Post3 months6 months
dfF or ?2a
1, 78 8.30.005 .45
CAPS–Total (?65) 1, 579.16.004.59
CAPS–Total (? 65)c
1, 18 .08.77 .12
PTSD Knowledge Test1, 76 12.73
? .001 .30
PTCI–Total 1, 78 14.19
? .001 .51
BDI–II1, 78 14.89
BAI 1, 78 5.14.03 .23
BPRS–Total1, 745.69 .02.45
WAI–Total1, 69 7.14.009.55
SF–12 Physical Component1, 73 10.27.002.07
SF–12 Mental Component 1, 7184.108.40.206
CAPS Dx CBT
CAPS Dx (? 65)e
CAPS Dx (? 65)e
usual; ES ? effect size comparing change from baseline to last assessment in CBT with change in TAU; PTCI ? Posttraumatic Cognitions Inventory;
BDI–II ? Beck Depression Inventory–II; BAI ? Beck Anxiety Inventory; BPRS ? Brief Psychiatric Rating Scale; WAI ? Working Alliance Inventory;
SF–12 ? Short Form; Dx ? diagnosis.
aFigures in this column are F values for the Continuous Variables section and ?2values for the Categorical Variables section.
CAPS ? Clinician Administered PTSD Scale; PTSD ? posttraumatic stress disorder; CBT ? cognitive–behavioral therapy; TAU ? treatment as
bValues are given as mean
dValues are given as number
cFull model unestimable; tested includes baseline as covariate and treatment group as independent variable.
eFull model unestimable; tested includes treatment group as independent variable.
CBT FOR PTSD IN SEVERE MENTAL ILLNESS
the individual CBT program. Research is needed to evaluate dif-
ferent treatment formats and programs for PTSD in clients with
severe mental illness.
Despite the high rates of PTSD in borderline personality disor-
der (Golier et al., 2003; Mueser et al., 1998; Zanarini et al., 1998),
limited research has evaluated the treatment of PTSD in this
population. Two randomized controlled trials of CBT programs for
the general population, both involving exposure therapy and either
stress inoculation training (Feeny, Zoellner, & Foa, 2002) or
cognitive restructuring (Hembree, Cahill, & Foa, 2004), reported
similar effects for respective subgroups of 9 and 3 clients with
borderline personality disorder compared with other clients. In
addition, case studies have demonstrated the feasibility and prom-
ise of combining exposure therapy with either stress inoculation
and social skills training (Mueser & Taylor, 1997) or dialectical
behavior therapy (Harned & Linehan, in press) for PTSD in
borderline personality disorder. The present study is unique both in
the number of clients included and its evaluation of a nonexposure
approach to PTSD. The finding that the 27 clients with borderline
personality disorder in this study did not differ in treatment re-
sponse from the 81 clients without it suggests that the burden of
PTSD can be reduced in this population and that exposure therapy
may not be a necessary ingredient.
Several limitations of this study should be noted. First, the use
of TAU as a control condition leaves open the question of whether
an attention control group would have yielded weaker results.
However, research on the treatment of PTSD in the general pop-
ulation has consistently found that CBT is more effective than
nonspecific “supportive” therapies (Bradley et al., 2005). Never-
theless, future research should consider comparing the CBT for
PTSD program to more active comparison treatments, such as
interventions designed to address the broad range of trauma se-
quelae (Harris, 1998) or exposure-based approaches (Frueh et al.,
2004). Second, the study was conducted in relatively rural northern
New England, where there are lower rates of poverty, homeless-
ness, and crime and less representation of racial and ethnic minor-
ity groups, pointing to the need to evaluate the CBT program in
more urban settings with more disadvantaged clients. Third, the
measures focused primarily on PTSD and other psychiatric symp-
toms, leaving open the question of the broader impact of the CBT
program on functional outcomes, course of psychiatric disorder,
and service utilization and costs. Fourth, information on prescribed
medications was not obtained, raising the question of whether
differences in medication could account for some of the differ-
ences between groups. Finally, a heterogeneous group of clients
with severe mental illness was studied, leading to low statistical
power to detect possible differences between diagnostic groups in
response to the CBT program, and potentially spurious findings for
the few interactions that were found. A related concern is that only
15% of the sample had schizophrenia or schizoaffective disorder,
despite the high rate of PTSD in this population (Calhoun et al.,
2007; Mueser, Salyers, et al., 2004), suggesting that more research
is needed to evaluate the program in this population.
Several strengths of the study are also noteworthy. Despite the
high rates of PTSD in clients with severe mental illness (Mueser et
al., 2002), this study is the first to evaluate a standardized treat-
ment for PTSD in this population in a randomized controlled trial.
The CBT program was successfully implemented across four
centers providing comprehensive mental health services, with ex-
cellent retention of clients in treatment and positive effects of the
program on PTSD and other outcomes. The findings support the
feasibility and clinical benefits of treating PTSD in clients with
severe mental illness, which is encouraging in light of recent
initiatives to develop trauma services for this population (Harris &
Fallot, 2001; Jennings, 2004). Further research is needed to eval-
uate the CBT for PTSD program in other settings and to determine
its longer-term impact on both mental health and service utilization
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Received May 31, 2007
Revision received September 18, 2007
Accepted September 28, 2007 ?
CBT FOR PTSD IN SEVERE MENTAL ILLNESS