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Cognitive-behavioral group treatment for PTSD: Design of a hybrid efficacy-effectiveness clinical trial
... The literature on efficacy and effectiveness of group treatments for PTSD is less well-developed, compared to the literature on individual treatments (e.g., Beck & Sloan, in press). Despite this relative lack of empirical foundation, group treatment approaches are used often in clinical settings, particularly within the Department of Veteran Affairs (e.g., Sloan, Unger, & Beck, 2016). To expand this literature, Sloan, Unger, Lee, and Beck (2018) compared gCBT with gPCT. ...
... A detailed description of the study procedures can be found in Sloan et al. (2016). Following recruitment, participants completed informed consent. ...
To examine moderators of change during group-based intervention for Posttraumatic Stress Disorder (PTSD), multilevel models were used to assess trajectories of symptom clusters in male veterans receiving trauma focused Group Cognitive Behavioral Treatment (gCBT; N = 84) or non-trauma focused Group Present Centered Therapy (gPCT; N = 91; Sloan et al., 2018). Separate models were conducted for symptom clusters in each intervention, examining pre-treatment PTSD symptoms, pre-treatment depression severity, age, index trauma, and outcome expectancies as potential moderators. Unconditioned growth models for both gCBT and gPCT showed reductions in intrusions, avoidance, negative cognitions/mood, and arousal/reactivity (all p < .001). Distinct moderators of recovery emerged for each treatment. Reductions in avoidance during gCBT were strongest at high levels of pre-treatment PTSD symptoms (low PTSD: p = .964, d = .05; high PTSD: p < .001, d = 1.31) whereas positive outcome expectancies enhanced reductions in cognitions/mood (low Expectancy: p = .120, d = .50; high Expectancy: p < .001, d = 1.13). For gPCT, high levels of pre-treatment depression symptoms negatively impacted change in both intrusion (low depression: p < .001, d = .96; high depression: p = .376, d = .22) and arousal/reactivity (low depression: p < .001, d = .95; high depression: p = .092, d = .39) symptoms. Results support the importance of examining trajectories of change and their moderators for specific treatments, particularly when contrasting trauma focused and non-trauma focused treatments.
... Study 1 (n ϭ 149) was designed to evaluate the psychometric properties of the CAPS-5 and PCL-5, enrolling veterans who endorsed at least one lifetime DSM-5 Criterion A traumatic event and at least one PTSD symptom in the previous month. Study 2 was a clinical trial for PTSD with 229 treatment-seeking male veterans who completed a baseline assessment (Sloan, Unger, & Beck, 2016). Participants were required to be age 18 or older and able to read and speak English. ...
... Participants were recruited from a VA Medical Center. After providing written informed consent, the CAPS-5 and PCL-5 were administered as part of the larger assessment battery (Sloan et al., 2016;Weathers et al., 2018). Participants completed the CAPS-5 and PCL-5 in relation to the same (worst) traumatic event between zero and six days of one another. ...
Network theory, which conceptualizes psychiatric disorders as networks of interacting symptoms, may provide a useful framework for understanding psychopathology. However, questions have arisen regarding the stability and generalizability of network analytic methods, with some researchers arguing that symptom networks have limited replicability. The aim of this study was to evaluate assessment modality as one possible source of instability in the estimation of posttraumatic stress disorder (PTSD) symptom networks. We estimated two cross-sectional DSM–5 PTSD symptom networks in 378 U.S. veterans: one using data from a clinician-rated assessment instrument (Clinician-Administered PTSD Scale for DSM–5; CAPS-5) and one using data from a self-rated questionnaire (the PTSD Checklist for DSM–5; PCL-5). We calculated centrality indices, conducted community structure analyses, and compared the strength and structure of the networks. The CAPS-5 and PCL-5 symptom networks were highly similar, challenging the notion that network methods produce unreliable results due to estimations consisting primarily of measurement error. Furthermore, each network contained distinct symptom communities that only partially overlapped with the DSM–5 PTSD symptom clusters. These findings may provide guidance for future revisions of the DSM, suggest hypotheses about how PTSD symptoms interact, and inform recent debate about replicability of psychopathology symptom networks.
... Sample 2 consisted of 207 male veterans who completed the baseline assessment of an ongoing clinical trial (Sloan, Unger, & Gayle Beck, 2016). Eligible veterans were invited to complete an initial assessment (see Sloan et al., 2016 for a detailed overview of study procedures). ...
... Sample 2 consisted of 207 male veterans who completed the baseline assessment of an ongoing clinical trial (Sloan, Unger, & Gayle Beck, 2016). Eligible veterans were invited to complete an initial assessment (see Sloan et al., 2016 for a detailed overview of study procedures). The only inclusion criteria for the present study were being a male veteran with an index event that met DSM-5 Criterion A, and self-identifying as being appropriate for a PTSD treatment study. ...
The Clinician-Administered PTSD Scale (CAPS) is an extensively validated and widely used structured diagnostic interview for posttraumatic stress disorder (PTSD). The CAPS was recently revised to correspond with PTSD criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). This article describes the development of the CAPS for DSM-5 (CAPS-5) and presents the results of an initial psychometric evaluation of CAPS-5 scores in 2 samples of military veterans (Ns = 165 and 207). CAPS-5 diagnosis demonstrated strong interrater reliability (к = .78 to 1.00, depending on the scoring rule) and test-retest reliability (к = .83), as well as strong correspondence with a diagnosis based on the CAPS for DSM-IV (CAPS-IV; к = .84 when optimally calibrated). CAPS-5 total severity score demonstrated high internal consistency (α = .88) and interrater reliability (ICC = .91) and good test-retest reliability (ICC = .78). It also demonstrated good convergent validity with total severity score on the CAPS-IV (r = .83) and PTSD Checklist for DSM-5 (r = .66) and good discriminant validity with measures of anxiety, depression, somatization, functional impairment, psychopathy, and alcohol abuse (rs = .02 to .54). Overall, these results indicate that the CAPS-5 is a psychometrically sound measure of DSM-5 PTSD diagnosis and symptom severity. Importantly, the CAPS-5 strongly corresponds with the CAPS-IV, which suggests that backward compatibility with the CAPS-IV was maintained and that the CAPS-5 provides continuity in evidence-based assessment of PTSD in the transition from DSM-IV to DSM-5 criteria. (PsycINFO Database Record
... It affirms the agency of participants because it does not place the researcher/ clinician in the role of director or healer, while supporting those who have an embodied experience of service at the forefront. The literature provides some evidence that there is no difference in symptom reduction between present-focused and trauma-focused therapies (Haagen, 2017;Sloan, Unger and Beck, 2016;Schnurr, et al., 2003Schnurr, et al., , 2009). What has not been adequately addressed in the literature is the welcoming of any story in a veterans group--that is, the fact that participants are veterans does not mean that the stories that they want or need to tell are connected to military service. ...
Background: UK and US military veterans can face challenges navigating civilian society, along with specific mental health conditions such as Posttraumatic Stress Disorder (PTSD). In this study brief group dramatherapy with veterans with clinical and subclinical PTSD symptom levels were brought together to operationalise the teamwork of the Forces in creative exercises. The goal was to facilitate story sharing as a therapeutic practice and as chosen by participants. This intervention was then assessed for its impact on participant wellbeing, sense of belonging and transition.
Methods: Using a mixed methods approach, this study triangulated qualitative narrative inquiry with quantitative outcome measures (for PTSD [PCL5], Changes in Outlook [a posttraumatic growth measure], Sense of Belonging and Community Reintegration of Service Members) with data collected over 14 months including before and after the group dramatherapy series (8 weekly 90-minute sessions), and at 3- and 12-months after. The findings were based on 4 separate groups (2 UK; 2 US). This study included 19 participants and was grounded in their words to guard against appropriation of the embodied experience of military service that the researcher did not have. Co-creation (co-production) was a part of the dramatherapy approach.
Findings: Main themes of homecoming and sense of belonging arose in all group contexts suggesting common transition challenges across decades. Reframing veteran-life challenges occurred in the group contexts to foster the creation of a narrative of capacity but also inhibited the sharing of some types of stories that were shared only in post-group interviews. Story sharing over the life course revealed that early-life and veteran-life traumas impacted wellbeing. An intervention focused solely on military service stories would miss this breadth of wellbeing stories. Participation reduced PTSD symptoms for more than half of participants over the year of the study, with sense of belonging enhanced for some participants during the group but not sustained for most once the group concluded suggesting a lower sense of belonging particularly for veterans living in civilian communities. Benefits from participation were greater for veterans who lived in civilian communities as compared to veterans in veteran-only communities who exhibited lower PTSD symptoms and a higher sense of belonging before, during and after the study.
Conclusion: Findings suggest recurring challenges for veterans across decades with some UK and US similarities and differences. Findings also suggest reconsidering group therapy to address stress and transition challenges faced by veterans over the life course. Also, the value of an ongoing group, with veterans deciding when and how long to attend, was suggested by participants.
Key words: brief group dramatherapy, veterans, wellbeing, sense of belonging, transition, Posttraumatic Stress Disorder, experts by experience
... This issue presents a particular stumbling block to reaching conclusions about a treatment's generalizability (Michelson et al., 2013). As a result, an increasing number of hybrid clinical trials have emerged that typically blend randomization with elements of effectiveness designs, including treatment delivery in a community-based setting (Kanter et al., 2015;Sloan et al., 2016). ...
The aim of this study was to examine the relative effectiveness of Collaborative and Proactive Solutions (CPS) and Parent Management Training (PMT) for youth with oppositional defiant disorder (ODD) in a community setting. Based on a semi-structured diagnostic interview, 160 youth with ODD (age 7-14; 72% male; ethnicity representative of the wider Australian population) were randomized to CPS (n = 81) or PMT (n = 79) for up to 16 weekly sessions. The primary hypothesis was that participants in the CPS group, treated in a community setting, would exhibit significant improvement in ODD, equivalent to that of an evidence-based treatment, PMT. Assessment was conducted at baseline, post-intervention, and at 6-month follow-up, using independently-rated semi-structured diagnostic interviews, parent-ratings of ODD symptoms, and global ratings of severity and improvement. Analyses were conducted with hierarchical growth linear modeling, ANCOVA, and equivalence testing using an intent-to-treat sample. Both treatments demonstrated similar outcomes, with 45-50% of youth in the non-clinical range after treatment, and 67% considered much improved. No differences were found between groups, and group equivalency was shown on the independent clinician and parent-rated measures. Gains were maintained at the 6-months follow-up. In conclusion, CPS works as effectively as the well-established treatment, PMT, for youth with ODD, when implemented in a community-based setting. As such, CPS provides a viable choice for families who seek alternate treatments.
... Thus, while adapting CBT techniques and application styles to another country or population, it is important to consider the culture that the individuals live in. Another limitation is that most of trauma literature about political violence belong to Western countries such as Canada and the US (Dossa & Hatem, 2012;Sloan, Unger & Beck, 2016;Garcia, Kelley, Rentz & Lee, 2011;Rauch et al., 2009). However, it is also known that political violence is more common in Eastern countries, especially in the Middle East. ...
Post-traumatic stress disorder (PTSD) is characterized as the psychological and emotional outcomes of experiencing a traumatic life event (Iribarren, Prolo, Neagos & Chiappelli, 2005). Potentially traumatic life events such as childhood traumas, sexual assaults, and political violence are very common and thus, post-traumatic stress disorder (PTSD) affects a large population. One of the most effective therapy techniques to treat PTSD symptoms is Cognitive Behavioral Therapy (CBT). CBT has different techniques for specific trauma types, and some examples for these techniques can be in vivo and imaginary exposure, psychoeducation, homework, and relaxation trainings. In this review, the effectiveness of CBT and its different methods on PTSD symptoms caused by different kinds of traumatic events, as well as the effectiveness of CBT across different populations were assessed. Overall, CBT is found to be a very effective technique for PTSD; however, it could be applied to a larger population who has developed PTSD.
... Of these participants, 15 (4.01%) were excluded because they completed the PCL-5 and CAPS-5 using different index events and 2 (1.20%) were excluded as they did not complete either the PCL-5 or the CAPS-5. The second sample included 230 veterans who completed the baseline assessment of an ongoing randomized controlled trial (see Sloan, Unger, & Beck, 2016 for a detailed overview of study procedures). All study procedures were approved by the VA Boston Health care System Institutional Review Board (protocol numbers 2625 and 2650). ...
The Cognitive Emotion Regulation Questionnaire–Short form (CERQ-Short; Garnefski & Kraaij, 2006) was developed to assess nine theoretically derived factors of emotion regulation. However, the psychometric properties of this measure have never been studied in a clinical sample. The present study examined the latent factor structure and construct validity of the CERQ-Short in two samples presenting for posttraumatic stress disorder treatment (N = 480). Results indicated that a six-factor solution, rather than the proposed nine factors, was the best-fitting measurement model. The original CERQ-Short factors of acceptance, positive refocusing, other-blame, and self-blame were retained. A novel perseveration factor incorporated both the original rumination and catastrophizing factors and a novel reappraisal factor incorporated items from the original positive reappraisal and putting into perspective factors. The revised six-factor measurement model provided good fit and demonstrated strong construct validity in a second clinical sample. Results support a more parsimonious six-factor CERQ-Short measurement model.
... Of these participants, 15 (4.01%) were excluded because they completed the PCL-5 and CAPS-5 using different index events and 2 (1.20%) were excluded as they did not complete either the PCL-5 or the CAPS-5. The second sample included 230 veterans who completed the baseline assessment of an ongoing randomized controlled trial (see Sloan, Unger, & Beck, 2016 for a detailed overview of study procedures). All study procedures were approved by the VA Boston Health care System Institutional Review Board (protocol numbers 2625 and 2650). ...
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) four-factor model of posttraumatic stress disorder (PTSD) has demonstrated adequate fit in several confirmatory factor analysis (CFA) studies. Although several alternative measurement models have demonstrated better fit, there is no consensus yet on the best model, and newly proposed models lack sufficient construct validation. Notably, these studies have relied exclusively on questionnaire data, and thus their findings may be attributable to a method effect. This study examined the factor structure of DSM-5 PTSD symptoms using both questionnaire and interview data to determine the impact of assessment method on the factor structure and construct validity of alternative model symptom clusters. Participants (N = 380) were veterans who completed the PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013) and Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers et al., 2013). Fit was similar across models. However, the seven-factor Hybrid model (Armour et al., 2015) fit best. Limited evidence of a method effect was observed. Results of construct validity analyses were mixed; some of the newly proposed symptom clusters demonstrated hypothesized differential associations with external correlates, but others did not. These findings suggest that results of previous DSM-5 PTSD CFAs supporting the Hybrid model are not attributable to a method effect. However, observed limited difference in model fit and mixed construct validity evidence raise concerns regarding the value of parsing DSM-5 symptom clusters. Constructs implied by the new factors in the more complex measurement models of PTSD require greater explication and construct validation.
... Thus, it is important that clinicians regularly and overtly draw connections between patients' real-life experiences and what occurs in group to increase patients' ability to generalize group processes and learning. One way to do this would be to have specific assignments based on the content of that week's group; for example, having patients practice assertiveness after a group session focused on assertiveness training (e.g., Sloan et al., 2016). Homework assignments could also be based on patients' insights. ...
One of the most potent protective factors against psychiatric symptoms after military trauma is perceived social support. Although group psychotherapy has been linked with increasing social support, no research has evaluated which therapeutic mechanisms are associated with this increase beyond symptom reduction. We investigated which interpersonal therapeutic factors were related to changes in social support, beyond posttraumatic stress disorder (PTSD) symptom reduction. Participants were 117 veterans in a multimodal outpatient group psychotherapy treatment designed to reduce PTSD symptoms and interpersonal difficulties. Generally, therapeutic factors were related to improvements in social support from baseline to posttreatment beyond the effects of PTSD symptom reduction. Specifically, social learning was associated with changes in appraisal support, secure emotional expression was associated with changes in tangible support, and neither was associated with changes in belonging support. Depending on the goals of treatment, understanding these variations are important so clinicians and researchers can appropriately design and target their interventions to facilitate desired changes.
Aim: The present study aimed to determine the effectiveness of cognitive-behavioral stress management in improving rumination and psychological distress in women faced with marital infidelity in Tehran in 2021. Methods: The present quasi-experimental study had a pretest-posttest design with a control group and a follow-up stage. The statistical population consisted of 94 women faced with infidelity who visited counseling centers in district 11 of Tehran. 40 eligible women were selected by the convenience sampling method and were randomly assigned to the experimental group (20 per group), and the control group (n=20). The experimental group received cognitive-behavioral stress management therapy by Anthony et al. (2009) for ten 90-minute sessions, and the control group was placed on the waiting list. The research tools included the rumination questionnaire by Nolen-Hoeksema and Morrow (1991) and the psychological distress scale by Lovibond (1995). The data obtained from the questionnaires were analyzed using SPSS24 and repeated-measures analysis of variance Results: The results indicated that cognitive-behavioral stress management (CBSM) was effective in reducing rumination (F=5.74, P=0.001), Depression (F=18.45, P=0.001), Anxiety (F=17.93, P=0.001) and Stress (F=17.05, P=0.001) in women faced with infidelity, and the effect was stable at the follow-up stage. Conclusion: According to the results, cognitive-behavioral stress management was an effective intervention in reducing rumination and psychological distress in women faced with husbands’ infidelity.
Group therapy is a frequently used therapy format for posttraumatic stress disorder (PTSD). However, factors contributing to treatment completion remain understudied. The current study examined predictors of treatment completion, defined as having completed 10 out of 14 sessions within 16 weeks, in veterans with PTSD who engaged in a hybrid efficacy–effectiveness randomized controlled trial of group psychotherapy for PTSD. Veterans (N = 198) were randomly assigned to 14 sessions of either group cognitive behavioral treatment (GBCT; n = 98) or group present‐centered treatment (GPCT; n = 100). Four primary domains of predictors were examined, encompassing sociodemographic factors, the severity of PTSD and comorbid conditions, modifiable predictors, and treatment condition. Multilevel binomial logistic regression models following the Fournier analysis approach were used to examine significant predictors within domains, which were then included in a final model. Overall, 70.7% of participants completed treatment (GCBT = 61.6%, GPCT = 79.8%). Participants in the GPCT condition were 2.389 times, 95% CI [1.394, 4.092], more likely to complete treatment than those in the GCBT condition. Older age, a higher income and level of educational attainment, more lifetime and current mental health diagnoses, and higher use of positive reappraisal ER skills predicted treatment completion. Higher levels of depressive symptoms, cumulative trauma burden, and use of positive refocusing ER skills predicted treatment noncompletion. These findings are discussed in the context of current clinical and research practices for examining treatment noncompletion, with attention to the inclusion of translational predictors.
Military members endure a variety of stressors (e.g., transitioning from military culture to college culture), which may be associated with mental health distress. College counselors must be aware of the unique clinical needs of student Veterans. College counselors can increase military cultural competence and adopt effective clinical approaches to better serve the unique mental health needs of student Veterans. This article provides a review of the common transitional stressors and mental health concerns experienced by student Veterans. Additionally, considerations for college counselors (developing military cultural competence, using effective clinical approaches) to serve student Veteran clients are discussed.
Despite high levels of traffic-related mortality, injury, and impairment among former service members, measures validated to assess problematic driving in this population remain limited. The current study examined characteristics of the Driving Behavior Survey (DBS) in male veterans (76.3% White; age: M = 56.4, SD = 12.3) meeting criteria for PTSD. Confirmatory factor analyses indicated acceptable fit of a 3-factor model specifying dimensions of anxiety-based performance deficits, exaggerated safety/caution, and hostile/aggressive driving behavior. Concurrent associations with indices of anxiety, depression, trauma history, and clinician-rated PTSD were consistent with small (r = .10-.29) to medium (r = .30-.49) effects. Discriminative validity was noted through elevations in performance deficit (d = .26), safety/caution (d = .50), and hostile/aggressive (d = .39) scales relative to published data from student drivers. Scores comparable to civilian motorists with accident-related PTSD help to qualify the severity of problematic driving behavior in trauma-exposed veterans.
Opioid use disorder (OUD) can encompass a number of behavioral, psychological, physiological, and interpersonal symptoms which collectively impair one’s functioning to different degrees. Of all the personal and societal problems associated with OUD, the most destructive and absolute is death. Given the caustic effects of OUD on quality of life and mortality, evidence-based pharmacotherapy and psychosocial interventions are necessary. It is the collective potential for buprenorphine to increase safety and concurrent cognitive-behavioral group therapy (CBGT) to address substance use triggers as well as comorbid psychiatric conditions, which makes this combination particularly promising for RCT of effectiveness. The purposes of this article are to (1) identify specific ethical issues which may hinder community partners from collaborating with clinical trialist wishing to conduct CBGT buprenorphine efficacy-effectiveness trials at their agency and (2) provide some basic guidelines (Yale CARE strategies) and methods for addressing these community partner ethical concerns. The purpose of the manuscript is to facilitate university and substance use/mental health center community collaborations that will result in ethical clinical trial methodology and findings that meaningfully translate to efficacious, effective, and generalizable CBGT and buprenorphine hybrid interventions for OUD.
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Objective:
Examine initial levels and pattern of change of alliance in group treatment for posttraumatic stress disorder (PTSD) for veterans.
Method:
One hundred and seventy-eight male veterans with PTSD were recruited for this study. Participants were randomly assigned to either group cognitive behavioral therapy (GCBT) or to group present-centered therapy (GPCT). Alliance with fellow group members was assessed every other session throughout the group (total of seven assessments). Hierarchical linear modeling was used to determine whether treatment condition or index trauma type (interpersonal or non-interpersonal) impacted initial levels of alliance or change in alliance over time.
Results:
Alliance increased significantly throughout treatment in both conditions. The presence of an interpersonal index event, compared to a non-interpersonal index event, did not significantly impact either initial levels of alliance or change in alliance over time. Participants in the GCBT condition experienced significantly greater growth in alliance over time compared to those in the GPCT condition (p > .05), but did not have significantly different initial alliance ratings.
Conclusions:
The components and focus of the GCBT treatment may have facilitated more rapid bonding among members. Interpersonal traumatic experience did not negatively impact group alliance.
To determine whether group therapy improves symptoms of posttraumatic stress disorder (PTSD), this randomized clinical trial compared efficacy of group cognitive processing therapy (cognitive only version; CPT-C) with group present-centered therapy (PCT) for active duty military personnel.
Patients attended 90-min groups twice weekly for 6 weeks at Fort Hood, Texas. Independent assessments were administered at baseline, weekly before sessions, and 2 weeks, 6 months, and 12 months posttreatment. A total of 108 service members (100 men, 8 women) were randomized. Inclusion criteria included PTSD following military deployment and medication stability. Exclusion criteria included suicidal/homicidal intent or other severe mental disorders requiring immediate treatment. Follow-up assessments were administered regardless of treatment completion. Primary outcome measures were the PTSD Checklist (Stressor Specific Version; PCL-S) and Beck Depression Inventory-II. The Posttraumatic Stress Symptom Interview (PSS-1) was a secondary measure.
Both treatments resulted in large reductions in PTSD severity, but improvement was greater in CPT-C. CPT-C also reduced depression, with gains remaining during follow-up. In PCT, depression only improved between baseline and before Session 1. There were few adverse events associated with either treatment.
Both CPT-C and PCT were tolerated well and reduced PTSD symptoms in group format, but only CPT-C improved depression. This study has public policy implications because of the number of active military needing PTSD treatment, and demonstrates that group format of treatment of PTSD results in significant improvement and is well tolerated. Group therapy may an important format in settings in which therapists are limited. (PsycINFO Database Record
(c) 2015 APA, all rights reserved).
In response to the growing numbers of veterans with posttraumatic stress disorder (PTSD), the Department of Veterans Affairs (VA) has sought to make evidence-based psychotherapies for PTSD available at every VA facility. We conducted a national survey of providers within VA PTSD clinical teams (PCTs) to describe utilization of prolonged exposure (PE) and cognitive processing therapy (CPT) and to identify individual and organizational factors associated with treatment uptake and adherence. Participants (N = 128) completed an electronic survey assessing reported utilization of PE and CPT treatments, adherence to treatment manuals, and characteristics of the provider and workplace environment. Participants reported conducting a weekly mean of 4.5 hours of PE, 3.9 hours of CPT (individual format), 1.3 hours of CPT (group format), and 13.4 hours of supportive care. Perceived effectiveness of PE and CPT were significantly associated with utilization of and adherence to those treatments. Reported number of hours conducting supportive care was positively associated with feeling the clinic was not sufficiently staffed (p = .05). Adherence to the PE treatment manual was positively associated with receiving emotional support from coworkers (p < .01). Provider attitudes and organizational factors such as staffing and work relationships may have an important impact on treatment selection and the quality of PTSD care provided in VA PCTs. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
Objective:
Many patients drop out of treatments for posttraumatic stress disorder (PTSD); some clinicians believe that trauma-focused treatments increase dropout.
Method:
We conducted a meta-analysis of dropout among active treatments in clinical trials for PTSD (42 studies; 17 direct comparisons).
Results:
The average dropout rate was 18%, but it varied significantly across studies. Group modality and greater number of sessions, but not trauma focus, predicted increased dropout. When the meta-analysis was restricted to direct comparisons of active treatments, there were no differences in dropout. Differences in trauma focus between treatments in the same study did not predict dropout. However, trauma-focused treatments resulted in higher dropout compared with present-centered therapy (PCT), a treatment originally designed as a control but now listed as a research-supported intervention for PTSD.
Conclusion:
Dropout varies between active interventions for PTSD across studies, but variability is primarily driven by differences between studies. There do not appear to be systematic differences across active interventions when they are directly compared in the same study. The degree of clinical attention placed on the traumatic event does not appear to be a primary cause of dropout from active treatments. However, comparisons of PCT may be an exception to this general pattern, perhaps because of a restriction of variability in trauma focus among comparisons of active treatments. More research is needed comparing trauma-focused interventions to trauma-avoidant treatments such as PCT.
Aspects of the reliability and criterion-related validity of the patient version of the California Psychotherapy Alliance Scales (CALPAS-P) were examined. The sample consisted of 147 patients consulting in private practice. Ss completed the 24-item CALPAS-P designed to assess 4 alliance dimensions. They also filled out questionnaires on symptomatology, intimacy problems, social desirability, and satisfaction. Coefficients of internal consistency varied from .43 to .73 for the 4 scales and reached .83 for the total CALPAS-P. Correlations among CALPAS-P scales ranged from .37 to .62. Patients', therapists', and treatments' characteristics were not related to CALPAS-P scales. Selected CALPAS-P scales were related to symptomatology and intimacy problems, whereas all scales were associated with satisfaction in therapy. No association was found between CALPAS-P scales and estimates of social desirability. Confirmatory factor analysis would help support the theoretically based dimensionality of the CALPAS-P. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The purpose of this article is to provide a brief review of group treatment for posttraumatic stress disorder (PTSD). This review includes a description of group-based treatments for PTSD and the available data on the efficacy of group treatment for PTSD. The literature review indicates that group treatment for PTSD is efficacious compared with no treatment. However, specific types of group treatment are not efficacious when compared with a nonspecific group treatment, such as psychoeducation or supportive counseling. Recommendations for practice and research are made in light of the available literature.
The current combat operations in Iraq and Afghanistan have involved US military personnel in major ground combat and hazardous security duty. Studies are needed to systematically assess the mental health of members of the armed services who have participated in these operations and to inform policy with regard to the optimal delivery of mental health care to returning veterans.
We studied members of 4 US combat infantry units (3 Army units and a Marine Corps unit) using an anonymous survey that was administered to the subjects either before their deployment to Iraq (n=2530) or 3 to 4 months after their return from combat duty in Iraq or Afghanistan (n=3671). The outcomes included major depression, generalized anxiety, and posttraumatic stress disorder (PTSD), which were evaluated on the basis of standardized, self-administered screening instruments.
Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6% to 17.1%) than after duty in Afghanistan (11.2%) or before deployment to Iraq (9.3%); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23% to 40% sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care.
This study provides an initial look at the mental health of members of the Army and the Marine Corps who were involved in combat operations in Iraq and Afghanistan. Our findings indicate that among the study groups there was a significant risk of mental health problems and that the subjects reported important barriers to receiving mental health services, particularly the perception of stigma among those most in need of such care. The recent military operations in Iraq and Afghanistan, which have involved the first sustained ground combat undertaken by the United States since the war in Vietnam, raise important questions about the effect of the experience on the mental health of members of the military services who have been deployed there. Research conducted after other military conflicts has shown that deployment stressors and exposure to combat result in considerable risks of mental health problems, including posttraumatic stress disorder, major depression, substance abuse, impairment in social functioning and in the ability to work, and the increased use of healthcare services. One study that was conducted just before the military operations in Iraq and Afghanistan began found that at least 6% of all US military service members on active duty receive treatment for a mental disorder each year. Given the ongoing military operations in Iraq and Afghanistan, mental disorders are likely to remain an important healthcare concern among those serving there. Many gaps exist in the understanding of the full psychosocial effect of combat. The all-volunteer force deployed to Iraq and Afghanistan and the type of warfare conducted in these regions are very different from those involved in past wars, differences that highlight the need for studies of members of the armed services who are involved in the current operations. Most studies that have examined the effects of combat on mental health were conducted among veterans years after their military service had ended. A problem in the methods of such studies is the long recall period after exposure to combat. Very few studies have examined a broad range of mental health outcomes near to the time of subjects' deployment. Little of the existing research is useful in guiding policy with regard to how best to promote access to and the delivery of mental health care to members of the armed services. Although screening for mental health problems is now routine both before and after deployment and is encouraged in primary care settings, we are not aware of any studies that have assessed the use of mental health care, the perceived need for such care, and the perceived barriers to treatment among members of the military services before or after combat deployment. We studied the prevalence of mental health problems among members of the US armed services who were recruited from comparable combat units before or after their deployment to Iraq or Afghanistan. We identified the proportion of service members with mental health concerns who were not receiving care and the barriers they perceived to accessing and receiving such care.
The long-term health consequences of war service remain unclear, despite burgeoning scientific interest. A longitudinal cohort study of a random sample of Australian Vietnam veterans was designed to assess veterans' postwar physical and mental health 36 years after the war (2005-2006) and to examine its relation to Army service, combat, and post-traumatic stress disorder (PTSD) assessed 14 years previously (1990-1993). Prevalences in veterans (n = 450) were compared with those in the Australian general population. Veterans' Army service and data from the first assessments were evaluated using multivariate logistic regression prediction modeling. Veterans' general health and some health risk factors were poorer and medical consultation rates were higher than Australian population expectations. Of 67 long-term conditions, the prevalences of 47 were higher and the prevalences of 4 were lower when compared with population expectations. Half of all veterans took some form of medication for mental well-being. The prevalence of psychiatric diagnoses exceeded Australian population expectations. Military and war service characteristics and age were the most frequent predictors of physical health endpoints, while PTSD was most strongly associated with psychiatric diagnoses. Draftees had better physical health than regular enlistees but no better mental health. Army service and war-related PTSD are associated with risk of illness in later life among Australian Vietnam veterans.
Little is known about how recent ISTSS practice guidelines (E. B. Foa, T. M. Keane, & M. J. Friedman, 2000) compare with prevailing PTSD treatment practices for veterans. Prior to guideline dissemination, clinicians in 6 VA medical centers were surveyed in 1999 (n = 321) and in 2001 (n = 271) regarding their use of various assessment and treatment procedures. Practices most consistent with guideline recommendations included psychoeducation, coping skills training, attention to trust issues, depression and substance use screening, and prescribing of SSRIs, anticonvulsants, and trazodone. PTSD and trauma assessment, anger management, and sleep hygiene practices were provided less consistently. Exposure therapy was rarely used. Additional research is needed on training, clinical resources, and organizational factors that may influence VA implementation of guideline recommendations.
The effects of war-zone deployment on neuropsychological health remain poorly understood. Neuropsychological performance deficits serve as sensitive measures of neural dysfunction and are often associated with psychosocial and occupational problems. Previous studies have not conducted objective neuropsychological assessments both before and after a major war-zone deployment.
To examine objective neuropsychological outcomes of Iraq War deployment in a large military cohort.
The Neurocognition Deployment Health Study, a prospective, cohort-controlled study conducted at military installations. This report centers on 961 male and female active-duty Army soldiers drawn from the larger cohort. Deploying Army soldiers (n = 654) were examined prior to deployment to Iraq (April-December 2003) and shortly after return (within a mean of 73 days [median, 75 days]; January-May 2005) from Iraq deployment. A comparison group of soldiers (n = 307) similar in military characteristics but not deploying overseas during the study was assessed in sessions timed to be as close as possible to the assessment of deployers. Military unit sampling procedures facilitated representation of combat, combat support, and combat service support functions among both deployers and nondeployers.
Individually administered, performance-based neuropsychological tasks. Estimates (beta; the unstandardized parameter estimate) for the absolute differences in adjusted mean outcome scores between deployed and nondeployed groups were determined using generalized estimating equations.
Multiple linear regression analyses adjusted for battalion membership revealed that Iraq deployment, compared with nondeployment, was associated with neuropsychological compromise on tasks of sustained attention (beta = 0.11; P<.001), verbal learning (beta = -1.51; P = .003), and visual-spatial memory (beta = -3.82; P<.001). Iraq deployment was also associated with increased negative state affect on measures of confusion (beta = 1.40; P<.001) and tension (beta = 1.24; P<.001). In contrast, deployment was associated with improved simple reaction time (beta = 4.30; P = .003). Deployment effects remained statistically significant after taking into account deployment-related head injury and stress and depression symptoms.
Deployment to Iraq is associated with increased risk of neuropsychological compromise. Findings point to the need to investigate further the impact of deployment on neural functioning. Public health implications include consideration of neuropsychological compromise in health prevention and postdeployment clinical and occupational management.
The prevalence of posttraumatic stress disorder (PTSD) is elevated among women who have served in the military, but no prior study has evaluated treatment for PTSD in this population. Prior research suggests that cognitive behavioral therapy is a particularly effective treatment for PTSD.
To compare prolonged exposure, a type of cognitive behavioral therapy, with present-centered therapy, a supportive intervention, for the treatment of PTSD.
A randomized controlled trial of female veterans (n=277) and active-duty personnel (n=7) with PTSD recruited from 9 VA medical centers, 2 VA readjustment counseling centers, and 1 military hospital from August 2002 through October 2005.
Participants were randomly assigned to receive prolonged exposure (n = 141) or present-centered therapy (n = 143), delivered according to standard protocols in 10 weekly 90-minute sessions.
Posttraumatic stress disorder symptom severity was the primary outcome. Comorbid symptoms, functioning, and quality of life were secondary outcomes. Blinded assessors collected data before and after treatment and at 3- and 6-month follow-up.
Women who received prolonged exposure experienced greater reduction of PTSD symptoms relative to women who received present-centered therapy (effect size, 0.27; P = .03). The prolonged exposure group was more likely than the present-centered therapy group to no longer meet PTSD diagnostic criteria (41.0% vs 27.8%; odds ratio, 1.80; 95% confidence interval, 1.10-2.96; P = .01) and achieve total remission (15.2% vs 6.9%; odds ratio, 2.43; 95% confidence interval, 1.10-5.37; P = .01). Effects were consistent over time in longitudinal analyses, although in cross-sectional analyses most differences occurred immediately after treatment.
Prolonged exposure is an effective treatment for PTSD in female veterans and active-duty military personnel. It is feasible to implement prolonged exposure across a range of clinical settings.
clinicaltrials.gov Identifier: NCT00032617.
This book first appeared in 1970 and has gone into two further editions, one in 1975 and this one in 1985. Yalom is also the author of Existential Psychotherapy (1980), In-patient Group Psychotherapy (1983), the co-author with Lieberman of Encounter Groups: First Facts (1973) and with Elkin of Every Day Gets a Little Closer: A Twice-Told Therapy (1974) (which recounts the course of therapy from the patient's and the therapist's viewpoint). The present book is the central work of the set and seems to me the most substantial. It is also one of the most readable of his works because of its straightforward style and the liberal use of clinical examples.
Objective:
To identify the extent to which evidence-based psychotherapy (EBP) and psychopharmacologic treatments for posttraumatic stress disorder (PTSD) are provided to U.S. service members in routine practice, and the degree to which they are consistent with evidence-based treatment guidelines.
Method:
We surveyed the majority of Army behavioral health providers (n = 2,310); surveys were obtained from 543 (26%). These clinicians reported clinical data on a total sample of 399 service member patients. Of these patients, 110 (28%) had a reported PTSD diagnosis. Data were weighted to account for sampling design and nonresponses.
Results:
Army providers reported 86% of patients with PTSD received evidence-based psychotherapy (EBP) for PTSD. As formal training hours in EBPs increased, reported use of EBPs significantly increased. Although EBPs for PTSD were reported to be widely used, clinicians who deliver EBP frequently reported not adhering to all core procedures recommended in treatment manuals; less than half reported using all the manualized core EBP techniques.
Conclusions:
Further research is necessary to understand why clinicians modify EBP treatments, and what impact this has on treatment outcomes. More data regarding the implications for treatment effectiveness and the role of clinical context, patient preferences, and clinical decision-making in adapting EBPs could help inform training efforts and the ways that these treatments may be better adapted for the military.
The Mini International Neuropsychiatric Interview (MINI) is a short diagnostic structured interview (DSI) developed in France and the United States to explore 17 disorders according to Diagnostic and Statistical Manual (DSM)-III-R diagnostic criteria. It is fully structured to allow administration by non-specialized interviewers. In order to keep it short it focuses on the existence of current disorders. For each disorder, one or two screening questions rule out the diagnosis when answered negatively. Probes for severity, disability or medically explained symptoms are not explored symptom-by-symptom. Two joint papers present the inter-rater and test-retest reliability of the Mini the validity versus the Composite International Diagnostic Interview (CIDI) (this paper) and the Structured Clinical Interview for DSM-IH-R patients (SCID) (joint paper). Three-hundred and forty-six patients (296 psychiatric and 50 non-psychiatric) were administered the MINI and the CIDI ‘gold standard’. Forty two were interviewed by two investigators and 42 interviewed subsequently within two days. Interviewers were trained to use both instruments. The mean duration of the interview was 21 min with the MINI and 92 for corresponding sections of the CIDI. Kappa coefficient, sensitivity and specificity were good or very good for all diagnoses with the exception of generalized anxietydisorder (GAD) (kappa = 0.36), agoraphobia (sensitivity = 0.59) and bulimia (kappa = 0.53). Inter-rater and test-retest reliability were good. The main reasons for discrepancies were identified. The MINI provided reliable DSM-HI-R diagnoses within a short time frame, The study permitted improvements in the formulations for GAD and agoraphobia in the current DSM-IV version of the MINI.
Between 2006 and 2012, the Department of Defense trained thousands of military mental health providers in the use of evidence-based treatments for post-traumatic stress disorder. Most providers were trained in multiday workshops that focused on the use of Cognitive Processing Therapy and Prolonged Exposure. This study is a follow-up evaluation of the implementation practices of 103 Air Force mental health providers. A survey was administered online to workshop participants; 34.2% of participants responded. Findings on treatment implementation with the providers indicated that a majority of respondents found the trainings valuable and were interested in using the treatments, yet they reported a lack of time in their clinic appointment structure to support their use. Insufficient supervision was also cited as a barrier to treatment use. Results suggest the need to improve strategies for implementing evidence-based practices with providers to enhance clinical outcomes in military settings.
Childhood sexual abuse (CSA) is a prevalent problem and the psychological and behavioral consequences are great. Despite this, we are still in the early stages of understanding how best to treat survivors of childhood sexual abuse. One fundamental question for treating CSA survivors is whether it is necessary or helpful for psychotherapists to focus on working through survivors' memories of childhood trauma in order to reduce current distress and improve functioning, or is it better to focus on current problems in living? Consequently, a pilot study was conducted among women who have been sexually abused as children and who meet the criteria for current PTSD as a result of that abuse. CSA survivors with PTSD were randomly assigned to one of three conditions: (1) a trauma-focused group psychotherapy, (2) a present-focused group psychotherapy, and (3) a waiting list no-treatment control condition. In this article, preliminary data on the question of whether group treatment of either type is better than no treatment is presented. Those who received group therapy resulted in a significant reduction in two kinds of trauma symptoms, dissociation and a sexual trauma index, and in two types of interpersonal problems, being vindictive and being nonassertive. When those individuals in the study with a history of having been sexually revictimized in the previous six months were isolated, at post-treatment only 38% of the women who were in the treatment group were revictimized compared to 67% of women in the wait-list condition. Given the small sample size, these differences were not statistically significant. However, a 50% reduction in revictimization is clinically significant. Further research with a larger sample of women is needed to confirm these findings and to test for differential effects of trauma focused group therapy and present focused group therapy.
Although patient compliance with homework assignments is considered a major component of cognitive therapy for depression, research studies have rarely investigated homework compliance as a variable potentially influencing treatment outcome. This paper reviews the literature on outcome studies of cognitive therapy for depression and describes research design problems that result from the failure to assess and control for differential homework compliance. These design problems limit the internal validity of outcome studies and make it difficult to compare studies that included allegedly similar treatments but produced different results. Recommendations for evaluating the role of homework compliance in outcome research on cognitive therapy and other treatment approaches are described. The need for adequate measures of homework compliance and quality is stressed, and potential criteria for use in cognitive therapy homework rating scales are proposed.
Posttraumatic stress disorder (PTSD) is a significant problem for a large number of veterans who receive treatment from the Department of Veterans Affairs (VA) health-care system. VA Cooperative Study 420 is a randomized clinical trial of group psychotherapy for treating PTSD among veterans who sought VA care. Participants at ten sites were randomly assigned to receive one of the two treatments: active treatment that embedded exposure therapy in a group context or comparison treatment that avoided trauma focus and instead addressed current interpersonal problems. Treatment was delivered weekly to groups of six participants for 30 weeks, followed by five monthly booster sessions. Follow-up assessments were conducted at the end of treatment (7 months) and the end of boosters (12 months) for all participants. Long-term follow-up data were collected for a subset of participants at 18 and 24 months. The primary outcome is PTSD severity; other symptoms, functional status, quality of life, physical health, and service utilization also were assessed. Data analysis will account for the clustering introduced by the group nature of the intervention. The pivotal comparison was at the end of treatment. Analyses of subsequent outcomes will concentrate on the question of the durability of effects. The study provides an example of how to address the unique challenges posed by multisite trials of group psychotherapy through attention to methodological and statistical issues. This article discusses these challenges and describes the design and methods of the study. Control Clin Trials 2001;22:74–88
The development and shaping of a general scale to assess client/patient satisfaction is reported. The scale, the CSQ, was constructed empirically by the authors. The CSQ is a response to several problems and issues that currently cloud the measurement of consumer satisfaction in health and human service systems. These problems and issues in assessing satisfaction are described. Finally, we present practical expriences to date in using the CSQ along with general psychometric qualities of the scale and correlations of CSQ results with client characteristics, service utilization, and service outcomes.
Four hundred and fifty college students rated the credibility of the rationales and procedural descriptions of two therapy, three placebo, and one component-control procedure frequently used in analogue outcome research. The rating scale was designed to assess both the credibility and the expectancy for improvement generated by the rationales. The results indicated that the control conditions were, in general, less credible than the therapy conditions. Implications for outcome research are briefly discussed.
The purpose of this investigation was to examine correlates of parent, child, and therapist treatment expectations and their role in the exposure-based treatment of childhood obsessive compulsive disorder (OCD). Treatment expectations were assessed among 49 youth with primary OCD, their parents, and therapists as part of the baseline evaluation and post-treatment clinical outcomes were determined by blind evaluators. Baseline depressive symptoms, child/parent-rated functional impairment, externalizing behavior problems, number of comorbid psychiatric disorders, and a lower perception of control were associated with lower pre-treatment expectations. Parent expectation was associated with parental OCD symptoms, child depressive symptoms and child-reported impairment. Therapist expectations inversely correlated with child depressive symptoms, externalizing problems, and child-rated impairment. Pre-treatment OCD severity and prior treatment history were not linked to expectancy. Finally, higher treatment expectations were linked to better treatment response, lower attrition, better homework compliance, and reduced impairment.
Differences in the characteristics and mental health needs of female veterans of the Iraq/Afghanistan war compared with those of veterans of other wars may have useful implications for VA program and treatment planning.
Female veterans reporting service in the Iraq/Afghanistan war were compared with women reporting service in the Persian Gulf and Vietnam wars and to men reporting service in the Iraq/Afghanistan war. Subjects were drawn from VA administrative data on veterans who sought outpatient treatment from specialized posttraumatic stress disorder (PTSD) treatment programs. A series of analyses of covariance (ANCOVA) was used to control for program site and age.
In general, Iraq/Afghanistan and Persian Gulf women had less severe psychopathology and more social supports than did Vietnam women. In turn, Iraq/Afghanistan women had less severe psychopathology than Persian Gulf women and were exposed to less sexual and noncombat nonsexual trauma than their Persian Gulf counterparts. Notable differences were also found between female and male veterans of the Iraq/Afghanistan war. Women had fewer interpersonal and economic supports, had greater exposure to different types of trauma, and had different levels of diverse types of pathology than their male counterparts.
There appear to be sufficient differences within women reporting service in different war eras and between women and men receiving treatment in VA specialized treatment programs for PTSD that consideration should be given to program planning and design efforts that address these differences in every program treating female veterans reporting war zone service.
Individuals with posttraumatic stress disorder (PTSD) related to a serious motor vehicle accident were randomly assigned to either group cognitive behavioral treatment(GCBT) or a minimum contact comparison group (MCC).Compared to the MCC participants (n=16), individuals who completed GCBT (n=17) showed significant reductions in PTSD symptoms, whether assessed using clinical interview or a self-report measure. Among treatment completers, 88.3% of GCBT participants did not satisfy criteria for PTSD at posttreatment assessment, relative to31.3% of the MCC participants. Examination of anxiety,depression, and pain measures did not show a unique advantage of GCBT. Treatment-related gains were maintained over a 3-month follow-up interval. Patients reported satisfaction with GCBT, and attrition from this treatment was comparable with individually administered CBTs.Results are discussed in light of modifications necessitated by the group treatment format, with suggestions for future study of this group intervention.
This study examined the relationship of compliance with homework assignments and posttreatment anxiety in patients who received cognitive-behavioral group therapy (CBGT) for social phobia. Greater homework compliance measured in the first and latter periods of CBGT was associated with lower levels of social interactional anxiety after treatment. Surprisingly, homework compliance during the middle sessions of CBGT was positively related to posttreatment fears of scrutiny and criticism. Perceptions of control in social phobia and their potential effect on homework compliance and the homework compliance/treatment outcome relationship were also examined using the Levenson (Journal of Consulting and Clinical Psychology, 41, 397-404, 1973) Locus of Control Scale. Social phobics were less likely to believe in their own control over events than a comparison sample of community subjects but attributed greater control over events to other powerful persons. Among patients, higher Internality and lower Powerful Others subscale scores were associated with higher levels of pretreatment anxiety. However, neither subscale was significantly related to measures of homework compliance. Furthermore, when included in multiple regression analyses, neither subscale or its interaction with homework compliance added to the prediction of posttreatment anxiety. Limitations of this study and future research to improve assessment of homework compliance and perceptions of control among social phobic patients are discussed.
The Mini-International Neuropsychiatric Interview (M.I.N.I.) is a short structured diagnostic interview, developed jointly by psychiatrists and clinicians in the United States and Europe, for DSM-IV and ICD-10 psychiatric disorders. With an administration time of approximately 15 minutes, it was designed to meet the need for a short but accurate structured psychiatric interview for multicenter clinical trials and epidemiology studies and to be used as a first step in outcome tracking in nonresearch clinical settings. The authors describe the development of the M.I.N.I. and its family of interviews: the M.I.N.I.-Screen, the M.I.N.I.-Plus, and the M.I.N.I.-Kid. They report on validation of the M.I.N.I. in relation to the Structured Clinical Interview for DSM-III-R, Patient Version, the Composite International Diagnostic Interview, and expert professional opinion, and they comment on potential applications for this interview.
Symptom exacerbation (i.e., treatment side effects) has often been neglected in the psychotherapy literature. Although prolonged exposure has gained empirical support for the treatment of chronic posttraumatic stress disorder (PTSD), some have expressed concem that imaginal exposure, a component of this therapy, may cause symptom exacerbation, leading to inferior outcome or dropout. In the present study, symptom exacerbation was examined in 76 women with chronic PTSD. To define a "reliable" exacerbation, we used a method incorporating the standard deviation and test-retest reliability of each outcome measure. Only a minority of participants exhibited reliable symptom exacerbation. Individuals who reported symptom exacerbation benefited comparably from treatment. Further, symptom exacerbation was unrelated to dropout. Thus, although a minority of individuals experienced a temporary symptom exacerbation, this exacerbation was unrelated to outcome.
The authors present a multidimensional meta-analysis of studies published between 1980 and 2003 on psychotherapy for PTSD.
Data on variables not previously meta-analyzed such as inclusion and exclusion criteria and rates, recovery and improvement rates, and follow-up data were examined.
Results suggest that psychotherapy for PTSD leads to a large initial improvement from baseline. More than half of patients who complete treatment with various forms of cognitive behavior therapy or eye movement desensitization and reprocessing improve. Reporting of metrics other than effect size provides a somewhat more nuanced account of outcome and generalizability.
The majority of patients treated with psychotherapy for PTSD in randomized trials recover or improve, rendering these approaches some of the most effective psychosocial treatments devised to date. Several caveats, however, are important in applying these findings to patients treated in the community. Exclusion criteria and failure to address polysymptomatic presentations render generalizability to the population of PTSD patients indeterminate. The majority of patients posttreatment continue to have substantial residual symptoms, and follow-up data beyond very brief intervals have been largely absent. Future research intended to generalize to patients in practice should avoid exclusion criteria other than those a sensible clinician would impose in practice (e.g., schizophrenia), should avoid wait-list and other relatively inert control conditions, and should follow patients through at least 2 years.
A diagnosis of chronic war-related posttraumatic stress disorder (PTSD) has been linked consistently to poor employment outcomes. This study investigates the relation further, analyzing how symptom severity correlates with work status, occupation type, and earnings. Study participants were male Vietnam veterans with severe or very severe PTSD who received treatment in the Department of Veterans Affairs system (N = 325). Veterans with more severe symptoms were more likely to work part-time or not at all. Among workers, more severe symptoms were weakly associated with having a sales or clerical position. Conditional on employment and occupation category, there was no significant relation between PTSD symptom level and earnings. Alternative PTSD symptom measures produced similar results. Our findings suggest that even modest reductions in PTSD symptoms may lead to employment gains, even if the overall symptom level remains severe.
Individual cognitive behavioral therapies (CBT) are now considered the first-line treatment for posttraumatic stress disorder (PTSD; Foa, Keane, & Friedman, 2000). As mental health reimbursement becomes more restricted, it is imperative that we adapt individual-format therapies for use in a small group format. Group therapies have a number of advantages, including provision of a natural support group, the ability to reach more patients, and greater cost efficiency. In this article, we describe the development of a group CBT for PTSD in the aftermath of a serious motor vehicle accident (MVA). Issues unique to the group treatment format are discussed, along with special considerations such as strategies to reduce the potential for triggering reexperiencing symptoms during group sessions. A case example is presented, along with discussion of group process issues. Although still in the early stages, this group CBT may offer promise as an effective treatment of MVA-related PTSD.
Seventy-eight motor vehicle accident survivors with chronic (greater than 6 months) PTSD, or severe sub-syndromal PTSD, completed a randomized controlled comparison of cognitive behavioral therapy (CBT), supportive psychotherapy (SUPPORT), or a Wait List control condition with two detailed assessments. Scores on the CAPS showed significantly greater improvement for those in CBT in comparison to the Wait List and to the SUPPORT conditions. The SUPPORT condition in turn was superior (p=0.012) to the Wait List. Categorical diagnostic data showed the same results. An analysis of CAPS scores including drop-outs (n=98) also showed CBT to be superior to Wait List and to SUPPORT with a trend for SUPPORT to be superior to Wait List. The CBT condition led to significantly greater reductions in co-morbid major depression and GAD than the other two conditions. Results held up well at a 3-month follow-up on the two active treatment conditions.
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