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A Naturalistic Study Exploring Mental Health Outcomes Following Trauma-Focused Treatment Among Diverse Survivors of Crime and Violence
Abstract
Background: Although considerable research has tested evidence-based practices in clinical
trials, research is needed on the use of trauma-focused treatments by victims of crime and
violence in naturalistic settings. This study investigated four trauma-focused treatments,
prolonged exposure therapy (PE), cognitive behavioral therapy (CBT), eclectic therapy, and
person-centered therapy (PCT), and assessed treatment dropout and symptom improvement over
five assessment time-points. Methods: Descriptive comparisons and pattern mixture multigroup
growth models were used to assess differences between treatments on time in treatment, rate of
dropout, and improvement in posttraumatic stress (PTSD) and depression symptoms in an
outpatient sample of 526 clients seeking routine clinical care. Results: PCT was significantly
associated with the highest number of therapy sessions completed and the lowest rate of dropout
(41.75%) compared to CBT and eclectic treatments. All treatment groups reported PTSD
symptom improvement with no significant differences based on therapy type. For depression,
the rate of improvement for clients in PCT who dropped out of treatment after session 3 was
significantly steeper than the rate of improvement for clients in eclectic treatment who dropped
out of treatment after session 3. Clients who stayed in treatment longer generally had larger
decreases in symptoms compared to those who dropped out earlier. Limitations: The small
sample size in each of the treatment groups may have limited power to detect change.
Conclusions: Several trauma-focused treatments offered in a community-based setting may
result in significant symptomatic improvement.
... For Latinos, the cultural norm of emphasizing family well-being, or familismo, over individual well-being might lead women to keep sexual assault experiences a secret in an effort to protect the family (Low and Organista 2001). Once Latinos seek mental health services, however, some studies have found that they are more likely to stay in treatment and benefit from treatment (Ghafoori et al. 2019;Ghafoori and Khoo 2020). ...
... The CBT-oriented therapies utilized a treatment manual. All treatments were delivered in up to twelve weekly sixty-to ninety-minute sessions; however, the current study only focused on the assessments up to the six-week time frame since the average number of sessions clients attend at the clinic is six sessions (Ghafoori et al. 2019). PE (Foe et al. 2007) included the following elements: psychoeducation about common reactions to trauma; breathing retraining; repeated imaginal exposure to the most distressing memory of the trauma during the therapy session; processing or discussing the content of the imaginal exposure during session; and repeated in-vivo exposure to a list of avoided people, places, or situations. ...
... Based on scoring guidelines, clients dropped from moderately severe (scores of 15-19) to mild (scores of 5-9) (Kroenke, Spitzer, and Williams 2001) depression after receiving CBT-oriented trauma focused EBPs for trauma related distress. These findings are consistent with the wide literature that suggests that participants benefit from receiving trauma-focused EBP treatment to address PTSD and depression (Ghafoori et al. 2019;APA 2017), and adds that trauma-focused EBPs provided in community mental health centers are effective for Latina sexual assault survivors. The correlation between the PTSD and depression measures was significant and very strong at all three time points (i.e., baseline, three sessions of treatment, and six sessions of treatment) of data collection. ...
... While strong empirical evidence supports the use of PE for PTSD, therapists often choose to offer supportive therapies for PTSD at community mental health centers (Ghafoori et al. 2017;Pingitore et al. 2001). Research suggests some reasons therapists may offer supportive therapies rather than evidence-based therapies for PTSD may include the fact that supportive therapies require little training and no adherence to a particular treatment protocol or structure (Barker-Collo and Read 2003;Ghafoori et al. 2019). Present centered therapy (PCT), a type of supportive therapy, is a trauma-focused therapy that is widely offered to patients in community based mental health centers for PTSD (Pingitore et al. 2001;Ghafoori et al. 2019). ...
... Research suggests some reasons therapists may offer supportive therapies rather than evidence-based therapies for PTSD may include the fact that supportive therapies require little training and no adherence to a particular treatment protocol or structure (Barker-Collo and Read 2003;Ghafoori et al. 2019). Present centered therapy (PCT), a type of supportive therapy, is a trauma-focused therapy that is widely offered to patients in community based mental health centers for PTSD (Pingitore et al. 2001;Ghafoori et al. 2019). Present centered therapy for PTSD includes psychoeducation about PTSD symptoms and assistance to patients in identifying current life problems and discussing them in a supportive, non-directive mode. ...
... Present centered therapy for PTSD includes psychoeducation about PTSD symptoms and assistance to patients in identifying current life problems and discussing them in a supportive, non-directive mode. Although some research suggests PCT may result in decreased PTSD symptoms (Ghafoori et al. 2019;Schnurr et al. 2007), other studies have found that PCT is less effective than trauma-focused cognitive behavioral treatments (Bisson et al. 2007). ...
The objective of this research was to investigate the relationship between race/ethnicity, intervention type, and mental health outcomes at 6 weeks into treatment in a low-income, diverse community-based sample of adults seeking treatment for traumatic stress. Adult patients (N = 163) received either prolonged exposure (PE) or present centered therapy (PCT). Results suggest significant within group differences with moderate to large effect sizes after six sessions of PE or PCT by race/ethnicity. Logistic regression analyses indicated that after adjusting for significant sociodemographic covariates, at the 6-week time-point the White group had increased likelihood of: probable PTSD compared to the Latinx group; probable anxiety compared to the Black group, Latinx group, and Other group; and probable depression compared to the Other group. Covariate adjusted models also found that at 6 weeks individuals in the PCT group had significantly greater odds of probable PTSD compared to those in the PE group. Implications for behavioral healthcare in a community-based setting are discussed.
... To make matters worse, treatment completion and effectiveness may be lower in a real-world setting compared to a research setting (Najavits, 2015). Indeed, recent studies show especially high dropout and nonresponse rates in naturalistic samples (Doran & DeViva, 2018;Ghafoori et al., 2019;Sripada et al., 2019). ...
... To test the robustness of the findings, a sensitivity analysis on the pri- There was a large and significant reduction in PTSD symptom severity between pretest and posttest, although more than half of the patients still met the criteria for likely PTSD at posttest. Similar findings have been reported in other evaluations of naturalistic treatment programmes (Asnaani et al., 2020;Clapp et al., 2016;Classen et al., 2017;Ghafoori et al., 2019). PD symptoms did not predict change in PTSD symptoms, whereas baseline symptom severity did predict symptom change. ...
Objective
To test the hypothesis that self‐rated personality disorder (PD) symptoms are a significant and clinically relevant predictor of treatment outcomes in a naturalistic treatment setting specialized in trauma‐focused treatment using a single‐group pretest–posttest design.
Method
Treatment‐seeking patients reporting clinical levels of posttraumatic stress disorder (PTSD) symptoms filled out questionnaires at intake and after treatment. The primary outcome was change in PTSD severity after treatment, measured by the PTSD Checklist for DSM‐5 (PCL‐5). PD symptoms were measured with the Structured Clinical Interview for DSM‐5 Screening Personality Questionnaire (SCID‐5‐SPQ). Secondary outcomes were general mental health problems, treatment response, number of sessions and dropout.
Results
N = 1174 patients (59% female, baseline PCL‐5 score M [SD] = 53.0 [10.8]) were included for the primary analysis. Regression analysis revealed that PD symptoms explained 0.4% of variance in PTSD symptom change ( p = .066). After controlling for baseline PTSD symptoms, PD symptoms explained 0.0% of variance ( p = .311). The fully adjusted model including baseline PTSD symptom severity, age, gender, cumulative exposure to potentially traumatic experiences, PD symptoms, and number of sessions together explained 5% of the observed variance in PTSD symptom change. Baseline PTSD severity was the only significant predictor and negatively predicted outcome. Sensitivity analyses with imputed data from N = 2694 cases yielded comparable results. Finally, secondary analyses showed that PD symptoms did not predict significant or clinically relevant changes in treatment response status, general mental health problems, dropout rates or number of sessions.
Conclusion
The findings provide no evidence that self‐rated PD symptoms predict treatment outcomes for patients suffering from clinical levels of PTSD symptoms in a naturalistic treatment setting specializing in trauma‐focused treatment. Self‐report screening for these symptoms to inform clinicians about expected effects of PTSD treatment is not supported by the evidence.
... Intervention with victims of HT is likely to be developed under approaches already tested and adopted for intervention with victims of other violent crimes, such as domestic violence, rape, abduction, or torture, since, by their very nature, are sensitive cases to trauma-centered approaches (Abas et al., 2013;Couto & Fernandes 2014;Ghafoori et al., 2019). ...
... It should also be addressed that, although HT has deep historical roots, public attention to it is recent, which means that at this stage, there are no specific intervention models tested and validated within this population (Freemire, 2017;Ghafoori et al., 2019;Villacampa & Torres, 2019). Nevertheless, and given the diversity of the effects of this type of victimization, the understanding of the scientific community has been that the intervention should be based on a combination of different approaches and therapeutic modalities depending on the intervention phase and the type of consequences and needs identified (Borschmann et al., 2017;Couto & Fernandes, 2014;Hornor, 2015). ...
This study aims to understand, through victims’ experiences, the impact and subsequent help-seeking and support process. The data was collected in institutional settings, through a semi-structured interview, from nine adult sheltered victims of labor exploitation of both sexes – 2 females and 7 males, aged between 42–67 years (M = 56.67; SD = 8.411). Thematic analysis was used, and three main themes emerged: formal support system, post-victimization and impact and traumas during formal support. The support provided to the victim was portrayed as effective and adequate; being able to meet the most basic and immediate needs. The victims trusted the police and the governmental institutions and were able to collaborate with the courts. The implications regarding the help-seeking system and public policy are discussed.
... Intervention with victims of HT is likely to be developed under approaches already tested and adopted for intervention with victims of other violent crimes, such as domestic violence, rape, abduction, or torture, since, by their very nature, are sensitive cases to trauma-centered approaches (Abas et al., 2013;Couto & Fernandes 2014;Ghafoori et al., 2019). ...
... It should also be addressed that, although HT has deep historical roots, public attention to it is recent, which means that at this stage, there are no specific intervention models tested and validated within this population (Freemire, 2017;Ghafoori et al., 2019;Villacampa & Torres, 2019). Nevertheless, and given the diversity of the effects of this type of victimization, the understanding of the scientific community has been that the intervention should be based on a combination of different approaches and therapeutic modalities depending on the intervention phase and the type of consequences and needs identified (Borschmann et al., 2017;Couto & Fernandes, 2014;Hornor, 2015). ...
This study aims to understand, through victims’ experiences, the impact and subsequent help-seeking and support process. The data was collected in institutional settings, through a semistructured interview, from nine adult sheltered victims of labor exploitation of both sexes – 2 females and 7 males, aged between 42–67 years (M = 56.67; SD = 8.411). Thematic analysis was used, and three main themes emerged: formal support system, post-victimization and impact and traumas during formal support. The support provided to the victim was portrayed as effective and adequate; being able to meet the most basic
and immediate needs. The victims trusted the police and the governmental institutions and were able to collaborate with the courts. The implications regarding the help-seeking system and public policy are discussed.
... Meta-analyses of trauma treatment suggest that 16%-65% of individuals who start an evidence-based treatment for traumatic distress drop out of treatment (Bradley et al., 2005;Goetter et al., 2015;Hembree et al., 2003;Imel et al., 2013;Lewis et al., 2020), and in naturalistic clinical settings that serve diverse low-income populations, dropout may be higher than in research trials due to an inability to fund engagement and retention efforts (Goetter et al., 2015). Dropout from PTSD treatment is typically considered a negative outcome because individuals may not be getting the optimal therapeutic dose for symptom and functional improvement; however, recent studies have suggested that some individuals who receive evidence-based trauma treatments may be dropping out when symptoms improve (Ghafoori et al. 2019;Szafranski et al., 2017). Little is known about dropout from trauma-focused treatment among survivors of interpersonal violence who are offered mental health treatment in community-based clinics. ...
Trauma‐focused psychotherapies are increasingly offered in community‐based mental health centers, but little is known about treatment dropout in these settings. The current study explored dropout at different stages of treatment in a treatment‐seeking sample of 1,186 adults who experienced interpersonal violence and were offered trauma‐focused and non–trauma‐focused therapies. A total of 31.6% of participants dropped out before treatment initiation, 28.0% dropped out after treatment initiation and completed a mean of 4.02 (SD = 2.41) sessions, and 40.4% completed a full course of PTSD treatment. Being unemployed, p < .001, and scoring lower on measures of environment factors, p = .045, were significant predictors of pretreatment dropout. Being female, p < .001; Latinx, p = .032; and scoring higher on a measure of social relationships, p = .024, were independent predictors of postinitiation dropout. Individuals who completed nine sessions of treatment displayed significantly lower levels of posttraumatic stress disorder, depression, and anxiety symptoms. The present study provides preliminary evidence that survivors of interpersonal violence who seek therapy tend to drop out early during treatment, and most who complete treatment attain symptom reduction.
... However, knowledge on trauma characteristics, mental health, the need for treatment and the families' further pathways through the healthcare system among a naturalistic sample [16,17] will provide valuable contributions to the development and implementation of treatment approaches for this vulnerable group. While for adult populations, few studies with unselected clinical samples are available [25,26], for children and adolescents, comparable data are scarce. ...
Only the minority of youth exposed to traumatic events receive mental health care, as trauma-informed clinical services are lacking or are poorly accessible. In order to bridge this gap, the Outpatient Trauma Clinic (OTC) was founded, an easily accessible early, short-time intervention , with onward referral to follow-up treatment. This report presents the OTC's interventional approach and first outcome data. Using a retrospective naturalistic design, we analyzed trauma-and intervention-related data of the sample (n = 377, 55.4% female, mean age 10.95, SD = 4.69). Following drop-out analyses, predictors for treatment outcome were identified by logistic regression. The majority (81.9%) was suffering from posttraumatic stress disorder (PTSD) or adjustment disorders. Around one forth dropped out of treatment; these cases showed higher avoidance symptoms at presentation. In 91%, psychological symptoms improved. Experience of multiple traumatic events was the strongest predictor for poor treatment outcome (B = −0.823, SE = 0.313, OR = 0.439, 95% CI 0.238-0.811). Around two thirds were connected to follow-up treatment. The OTC realized a high retention rate, initial improvement of symptoms and referral to subsequent longer-term psy-chotherapeutic treatment in the majority. Further dissemination of comparable early intervention models is needed, in order to improve mental health care for this vulnerable group.
Introducción: El Trastorno de Estrés Postraumático (TEPT) es un problema frente al que han surgido diferentes tratamientos surgiendo como una alternativa no focalizada en el trauma la Terapia Centrada en el Presente TCP.Desarrollo: Se realizó una revisión sistemática sobre la eficacia de la TCP para tratar el TEPT, se extrajeron 19 artículos que cumplieron con los criterios de inclusión y exclusión. En la mayoría de estudios se encontró que la TCP fue igual de eficaz que otras terapias, en otros que la eficacia de la TCP fue mayor y en otras menores, dependiendo de la diversidad de síntomas del TEPT y condiciones asociadas.Aplicaciones prácticas o futuras líneas de investigación: Es posible que existan diferencias particulares entre personas o entre sus síntomas que les permiten responder mejor a una terapia no centrada en el trauma que a una centrada en el trauma.Conclusiones: Se encontró igual eficacia de la TCP y otras terapias para algunos síntomas del TEPT, pero para otros no lo cual puede obedecer a diferencias individuales entre los sujetos o a diferencias entre los síntomas del TEPT La TCP como terapia no centrada en el trauma podría ser eficaz para personas que tengan complicaciones al revivir su experiencia traumáticaPalabras Clave: Trastorno de Estrés Postraumático, Psicoterapia, Terapia Centrada en el Presente.
The California Survey of Psychological Practice provides comprehensive data on patient case mix, treatments, practice settings, and payment sources using a representative sample of psychologists. These psychologists practice in diverse settings and continue to deliver traditional psychotherapies. California psychologists' treatment of persons with private insurance highlights the profession's public health contribution by improving the functioning of employed persons and their families. Despite high managed care enrollment among Californians, these psychologists demonstrate wide variability in managed care participation. The authors compare the findings to prior surveys among psychologists and discuss the findings in relation to trends in psychological practice and public policy.
The study aims were to determine whether prolonged exposure (PE) improved mental-health and was feasible to implement by frontline clinicians in a culturally diverse sample with complex trauma. Seventy-one individuals were randomly assigned to PE or person-centered therapy (PCT). Outcome measures were administered at baseline and sessions 3, 6, 9, and 12. Mixed modeling was used to regress outcome measures on time, treatment-group, and number of visits. Individuals who received PE showed significant moderate association with decline in reported PTSD symptoms as noted by the PCL-5 (p =.05) compared to PCT. Results indicated improved scores on all measures at each follow-up time point compared to baseline (p < .01). PE was feasible, shown by positive recruitment and ability of clinicians to effectively implement and maintain treatment fidelity. Findings suggest PE can be effective for treating complex trauma when used by clinicians in community settings.
Few studies have examined symptom change among dropouts from posttraumatic stress disorder (PTSD) treatment. However, dropout is widely considered a negative event needing to be addressed. The present study investigated PTSD and depression symptom change in patients with PTSD who discontinued psychotherapy. Female civilians (n = 321) diagnosed with PTSD participated in two randomized clinical trials examining PTSD treatment outcomes. Of those, 53 were identified as dropouts and included in this study. Symptom change was assessed by clinically significant change (CSC) criteria and symptom end-state criteria. Results demonstrated that considerable proportions of participants (35.85–55.56%) displayed significant improvement and/or met good end-state criteria for PTSD and depression. Results also revealed that participants who displayed symptom improvement were younger, attended more treatment sessions, were married or partnered, and had higher annual household income. Although preliminary, these findings contradict belief that treatment dropouts do not display symptom improvement.
Veterans returning from Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) display high rates of noncompletion from posttraumatic stress disorder (PTSD) treatment. The present study included 282 male OEF/OIF/OND Veterans and examined predictors of noncompletion from inpatient evidence-based treatment (EBT) for PTSD. Logistic regression analyses identified younger age, higher military rank, less improvement in symptom reduction, less improvement in overall functioning and greater concurrent drug use at admission as significant and unique predictors of noncompletion. Overall, these findings reveal clinically relevant predictors of noncompletion and provide information that may increase PTSD treatment completion.
The catastrophic events of September 11, 2001, significantly raised this country's interest in and concern about the psychological consequences of mass trauma and for good reason. Epidemiological studies conducted 1 to 2 months after 9/11 reported prevalence rates of posttraumatic stress disorder (PTSD) in Lower Manhattan of between 7–11% (Galea et al., 2002; Schlenger et al., 2002), a much higher figure than the 4% or less in the rest of the country (Schlenger et al., 2002). Other studies documented an increase in stress-related symptoms across the entire country in the immediate days and weeks after 9/11, although the prevalence of PTSD decreased substantially with distance from ground zero (Silver et al., 2002; Blanchard et al., 2004). In addition, there was a small, but statistically significant increase in the use of psychiatric medications among people living in Manhattan in the month following the attacks on the World Trade Center (Boscarino et al., 2003) and a substantial proportion (29%) of Manhattanites increased their use of alcohol, cigarettes, and marijuana 5–8 weeks later (Vlahov et al., 2002). Individuals who increased their substance use were more likely to experience PTSD and depression (Vlahov et al., 2002). These studies serve to illustrate the significant psychological impact even a single incident of terrorism can have and the need to have appropriate resources available to assist those who develop significant psychological difficulties in the aftermath of such an event. There has been substantial progress over the last 15 years in the development and validation of effective psychological treatments for PTSD.
Emerging data suggest that few veterans are initiating prolonged exposure (PE) and cognitive processing therapy (CPT) and dropout levels are high among those who do start the therapies. The goal of this study was to use a large sample of veterans seen in routine clinical care to 1) report the percent of eligible and referred veterans who (a) initiated PE/CPT, (b) dropped out of PE/CPT, (c) were early PE/CPT dropouts, 2) examine predictors of PE/CPT initiation, and 3) examine predictors of early and late PE/CPT dropout. We extracted data from the medical records of 427 veterans who were offered PE/CPT following an intake at a Veterans Health Administration (VHA) PTSD Clinical Team. Eighty-two percent (n = 351) of veterans initiated treatment by attending Session 1 of PE/CPT; among those veterans, 38.5% (n = 135) dropped out of treatment. About one quarter of veterans who dropped out were categorized as early dropouts (dropout before Session 3). No significant predictors of initiation were identified. Age was a significant predictor of treatment dropout; younger veterans were more likely to drop out of treatment than older veterans. Therapy type was also a significant predictor of dropout; veterans receiving PE were more likely to drop out late than veterans receiving CPT. Findings demonstrate that dropout from PE/CPT is a serious problem and highlight the need for additional research that can guide the development of interventions to improve PE/CPT engagement and adherence. (PsycINFO Database Record
(c) 2015 APA, all rights reserved).
High rates of attrition occur in outpatient and inpatient evidence-based treatments (EBTs) targeting newly returning veterans from Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) with posttraumatic stress disorder (PTSD). Traditionally, research has examined attrition as a dichotomous variable (i.e., noncompleters vs. completers) and focused almost exclusively on outpatient EBTs for PTSD. These studies have provided little information to inpatient psychiatric providers about timing-related predictors of treatment discontinuation. The present study attempted to mend these gaps by examining attrition as a continuous variable and investigated predictors of length of stay (LOS) among 282 OEF/OIF/OND male veterans, 69 of which did not complete the full 25-day intensive, multimodal inpatient PTSD EBT program. At admission, participants completed a series of clinician-rated, biological, and self-report assessments. Linear regression analyses were used to identify predictors of shorter LOS. The results demonstrated that less improvement in symptom reduction, overall functioning, and greater number of drugs used at admission were significant and unique predictors of shorter LOS. Overall, these findings reveal clinically relevant, timing-related predictors of attrition and provide generalizable clinical information to inpatient psychiatric providers.
To examine the evidence for present-centered therapy (PCT) as a treatment for posttraumatic stress disorder (PTSD), 5 randomized clinical trials that compared PCT to an existing evidence-based treatment for PTSD were reviewed. A meta-analysis was used to estimate between-treatment differences on targeted measures, secondary measures, and dropout. PCT was found to be as efficacious as the comparison evidence-based treatment in 3 of the 5 trials, and in the 2 cases where a no-treatment condition was included, PCT was superior, with large effect sizes for targeted variables (d = 0.88, 0.74, and 1.27). When results were aggregated using meta-analysis, effects for PCT versus an evidence-based treatment for both targeted and secondary measures were small and nonsignificant (d = 0.13 and d = 0.09, respectively). As well, the dropout rate for PCT was significantly less than for the comparison evidence-based treatments (14.3% and 31.3%, respectively). It appears that PCT is an efficacious and acceptable treatment for PTSD.
Trauma-focused psychological treatments are recommended as first-line treatments for Posttraumatic Stress Disorder (PTSD), but clinicians may be concerned that the good outcomes observed in randomized controlled trials (RCTs) may not generalize to the wide range of traumas and presentations seen in clinical practice. This study investigated whether Cognitive Therapy for PTSD (CT-PTSD) can be effectively implemented into a UK National Health Service Outpatient Clinic serving a defined ethnically mixed urban catchment area.
A consecutive sample of 330 patients with PTSD (age 17-83) following a wide range of traumas were treated by 34 therapists, who received training and supervision in CT-PTSD. Pre and post treatment data (PTSD symptoms, anxiety, depression) were collected for all patients, including dropouts. Hierarchical linear modeling investigated candidate moderators of outcome and therapist effects.
CT-PTSD was well tolerated and led to very large improvement in PTSD symptoms, depression and anxiety. The majority of patients showed reliable improvement/clinically significant change: intent-to-treat: 78.8%/57.3%; completer: 84.5%/65.1%. Dropouts and unreliable attenders had worse outcome. Statistically reliable symptom exacerbation with treatment was observed in only 1.2% of patients. Treatment gains were maintained during follow-up (M = 280 days, n = 220). Few of the selection criteria used in some RCTs, demographic, diagnostic and trauma characteristics moderated treatment outcome, and only social problems and needing treatment for multiple traumas showed unique moderation effects. There were no random effects of therapist on symptom improvement, but therapists who were inexperienced in CT-PTSD had more dropouts than those with greater experience.
The results support the effectiveness of CT-PTSD and suggest that trauma-focused cognitive behavior therapy can be successfully implemented in routine clinical services treating patients with a wide range of traumas.
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.
Objective: This article examines survivor perspectives of the effectiveness of two different treatments for trauma symptoms among adult female survivors of childhood sexual abuse--Eye movement Desensitization and Reprocessing (EMDR) and eclectic therapy. Method: Qualitative interviews obtained in the context of a mixed-methods study were conducted with 38 adult female survivors of childhood sexual abuse. Results: Two major differences in outcomes between the two treatment approaches were observed. There were considerable distinctions between the two treatment groups in terms of the importance and effect of the client-therapist relationship, and in terms of the depth of change reportedly caused by the different therapies. Conclusions: Survivors' narratives indicate that EMDR produces greater trauma resolution, while within eclectic therapy, survivors more highly value their relationship with their therapist, through whom they learn effective coping strategies.
Posttraumatic stess disorder (PTSD) is associated with functional impairment, co-occurring diagnoses, and increased health care utilization. Associated high demand for health care services is an important contributor to the large public-health cost of PTSD. Treatments incorporating exposure therapy are efficacious in ameliorating or eliminating PTSD symptoms. Accordingly, the Veterans Health Administration has made significant investments toward nationwide dissemination of a manualized exposure therapy protocol, prolonged exposure (PE). PE is effective with veterans; however, the relationship between PE and mental health service utilization is unknown. The current study investigates PE as it relates to actual tracked mental health service utilization in an urban VA medical center. A sample of 60 veterans with a diagnosis of PTSD was used to examine mental health service utilization in the 12-months prior to and 12-months after being offered PE. Hierarchical Linear Models and traditional repeated-measures ANOVA were used to estimate R2- and d-type effect sizes for service utilization. Associated estimated cost saving are reported. PE was associated with large reductions in symptoms and diagnosis remission. Treatment was also associated with statistically significant, large reductions in mental health service utilization for veterans who completed treatment. Findings suggest that expanding access to PE can increase access to mental health services in general by decreasing ongoing demand for specialty care clinical services. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
Objective:
This study tested a modified cognitive processing therapy (MCPT) intervention designed as a more flexible administration of the protocol. Number of sessions was determined by client progress toward a priori defined end-state criteria, "stressor sessions" were inserted when necessary, and therapy was conducted by novice CPT clinicians.
Method:
A randomized, controlled, repeated measures, semicrossover design was utilized (a) to test the relative efficacy of the MCPT intervention compared with a symptom-monitoring delayed treatment (SMDT) condition and (b) to assess within-group variation in change with a sample of 100 male and female interpersonal trauma survivors with posttraumatic stress disorder (PTSD).
Results:
Hierarchical linear modeling analyses revealed that MCPT evidenced greater improvement on all primary (PTSD and depression) and secondary (guilt, quality of life, general mental health, social functioning, and health perceptions) outcomes compared with SMDT. After the conclusion of SMDT, participants crossed over to MCPT, resulting in a combined MCPT sample (n = 69). Of the 50 participants who completed MCPT, 58% reached end-state criteria prior to the 12th session, 8% at Session 12, and 34% between Sessions 12 and 18. Maintenance of treatment gains was found at the 3-month follow-up, with only 2 of the treated sample meeting criteria for PTSD. Use of stressor sessions did not result in poorer treatment outcomes.
Conclusions:
Findings suggest that individuals respond at a variable rate to CPT, with significant benefit from additional therapy when indicated and excellent maintenance of gains. Insertion of stressor sessions did not alter the efficacy of the therapy.
Abstract This study describes the psychological interventions used for eating disorders (EDs) by community practitioners. Of 573 clinicians we screened across Alberta, 130 (22.7%) had treated EDs; 118 (90.8%) were interviewed. Clinicians reported varied reasons for psychotherapy choice and diverse training experiences; the primary approaches used varied by education and field. The most common primary approach was eclectic (43.2%), followed by cognitive-behavior therapy (CBT; 22.9%). However, self-reported CBT clinicians used specific CBT techniques infrequently. Half of clinicians incorporated addictions-based techniques. These results indicate that ED treatment provided by community clinicians is varied and generally does not align with evidence-based practice guidelines.
A longitudinal approach was used to examine the effects of parental task-intrinsic and task-extrinsic motivational practices on academic intrinsic motivation in the subject areas of math and science. Parental task-intrinsic practices comprise encouragement of children’s pleasure and engagement in the learning process, whereas task-extrinsic practices comprise parents’ provision of external rewards and consequences contingent on children’s task performance. A conditional latent curve model was fit to data from the Fullerton Longitudinal Study (A. W. Gottfried, A. E. Gottfried, & D. W. Guerin, 2006), with academic intrinsic motivation in math and science assessed from ages 9 to 17 and parental motivational practices measured when children were age 9. The results indicated that task-intrinsic practices were beneficial with regard to children’s initial levels of motivation at age 9 as well as with regard to motivational decline through age 17. Conversely, parents’ use of task-extrinsic practices was adverse with regard to children’s motivation both at age 9 and across the 8-year interval. Theoretical implications of the findings with regard to academic intrinsic motivation are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Cognitive–behavioral therapies (CBTs) can be effective treatments for posttraumatic stress disorder (PTSD) but their effectiveness is limited by high rates of premature dropout. Few studies have compared pretreatment characteristics of treatment completers and dropouts, and only one has examined these factors in Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) Veterans. This study analyzed archival clinical data from 117 OEF/OIF Veterans evaluated and treated through a Veterans Affairs PTSD clinic. High numbers dropped out of treatment (68%). Treatment dropouts (n = 79) and completers (n = 38) differed significantly on Minnesota Multiphasic Personality Inventory-2 (MMPI-2) scales, PTSD symptom severity, and age. Regression analyses identified one MMPI-2 scale, TRT (negative treatment indicators), and age as unique but modest predictors of dropout. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Random-effects regression models have become increasingly popular for analysis of longitudinal data. A key advantage of the random-effects approach is that it can be applied when subjects are not measured at the same number of timepoints. In this article we describe use of random-effects pattern-mixture models to further handle and describe the influence of missing data in longitudinal studies. For this approach, subjects are first divided into groups depending on their missing-data pattern and then variables based on these groups are used as model covariates. In this way, researchers are able to examine the effect of missing-data patterns on the outcome (or outcomes) of interest. Furthermore, overall estimates can be obtained by averaging over the missing-data patterns. A psychiatric clinical trials data set is used to illustrate the random-effects pattern-mixture approach to longitudinal data analysis with missing data. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Prolonged exposure (PE) is an effective first-line treatment for posttraumatic stress disorder (PTSD), regardless of the type of trauma, for Veterans and military personnel. Extensive research and clinical practice guidelines from various organizations support this conclusion. PE is effective in reducing PTSD symptoms and has also demonstrated efficacy in reducing comorbid issues such as anger, guilt, negative health perceptions, and depression. PE has demonstrated efficacy in diagnostically complex populations and survivors of single- and multiple-incident traumas. The PE protocol includes four main therapeutic components (i.e., psychoeducation, in vivo exposure, imaginal exposure, and emotional processing). In light of PE's efficacy, the Veterans Health Administration designed and supported a PE training program for mental health professionals that has trained over 1,300 providers. Research examining the mechanisms involved in PE and working to improve its acceptability, efficacy, and efficiency is underway with promising results.
Community mental health clinicians are likely to find their case loads composed of women who have complicated trauma histories. In response to the absence of comprehensive treatment for trauma survivors within the community mental health system, an alternative model, Overcoming Pain and Adversity in Life (OPAL) is offered. As an intensive treatment program, OPAL is structured in a triphase format to accommodate the individual needs of each woman and to promote symptom reduction and/or resolution.
This article uses a general latent variable framework to study a series of models for nonignorable missingness due to dropout. Nonignorable missing data modeling acknowledges that missingness may depend not only on covariates and observed outcomes at previous time points as with the standard missing at random assumption, but also on latent variables such as values that would have been observed (missing outcomes), developmental trends (growth factors), and qualitatively different types of development (latent trajectory classes). These alternative predictors of missing data can be explored in a general latent variable framework with the Mplus program. A flexible new model uses an extended pattern-mixture approach where missingness is a function of latent dropout classes in combination with growth mixture modeling. A new selection model not only allows an influence of the outcomes on missingness but allows this influence to vary across classes. Model selection is discussed. The missing data models are applied to longitudinal data from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, the largest antidepressant clinical trial in the United States to date. Despite the importance of this trial, STAR*D growth model analyses using nonignorable missing data techniques have not been explored until now. The STAR*D data are shown to feature distinct trajectory classes, including a low class corresponding to substantial improvement in depression, a minority class with a U-shaped curve corresponding to transient improvement, and a high class corresponding to no improvement. The analyses provide a new way to assess drug efficiency in the presence of dropout.
The purpose of this article is to examine the literature on the increased risk factors of disadvantaged inner-city residents for becoming victims of violence and for developing posttraumatic stress disorder (PTSD) and barriers to accessing comprehensive mental health services. Second, the article discusses the limitations of evidence-based treatments for early intervention with urban victims of violence and provides a new model of care emphasizing outreach, engagement, and practical assistance. Finally, the article concludes with recommendations for comprehensive hospital-based urban programs in terms of practice, policy, and research.
Cognitive processing therapy (CPT) was developed to treat the symptoms of posttraumatic stress disorder (PTSD) in rape victims. CPT is based on an information processing theory of PTSD and includes education, exposure, and cognitive components. Nineteen sexual assault survivors received CPT, which consists of 12 weekly sessions in a group format. They were assessed at pretreatment, posttreatment, and 3- and 6-month follow-up. CPT subjects were compared with a 20-subject comparison sample, drawn from the same pool who waited for group therapy for at least 12 weeks. CPT subjects improved significantly from pre- to posttreatment on both PTSD and depression measures and maintained their improvement for 6 months. The comparison sample did not change from the pre- to the posttreatment assessment sessions.
Meta-analyses were conducted on 14 separate risk factors for posttraumatic stress disorder (PTSD), and the moderating effects of various sample and study characteristics, including civilian/military status, were examined. Three categories of risk factor emerged: Factors such as gender, age at trauma, and race that predicted PTSD in some populations but not in others; factors such as education, previous trauma, and general childhood adversity that predicted PTSD more consistently but to a varying extent according to the populations studied and the methods used; and factors such as psychiatric history, reported childhood abuse, and family psychiatric history that had more uniform predictive effects. Individually, the effect size of all the risk factors was modest, but factors operating during or after the trauma, such as trauma severity, lack of social support, and additional life stress, had somewhat stronger effects than pretrauma factors.
The Life Events Checklist (LEC), a measure of exposure to potentially traumatic events, was developed at the National Center for Posttraumatic Stress Disorder (PTSD) concurrently with the Clinician Administered PTSD Scale (CAPS) to facilitate the diagnosis of PTSD. Although the CAPS is recognized as the gold standard in PTSD symptom assessment, the psychometric soundness of the LEC has never been formally evaluated. The studies reported here describe the performance of the LEC in two samples: college undergraduates and combat veterans. The LEC exhibited adequate temporal stability, good convergence with an established measure of trauma history—the Traumatic Life Events Questionnaire (TLEQ)— and was comparable to the TLEQ in associations with variables known to be correlated with traumatic exposure in a sample of undergraduates. In a clinical sample of combat veterans, the LEC was significantly correlated, in the predicted directions, with measures of psychological distress and was strongly associated with PTSD symptoms.
High rates of comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD) have been noted in veteran populations. Fortunately, there are a number of evidence-based psychotherapies designed to address comorbid PTSD and SUD. However, treatments targeting PTSD and SUD simultaneously often report high dropout rates. To date, only one study has examined predictors of dropout from PTSD/SUD treatment. To address this gap in the literature, this study aimed to 1) examine when in the course of treatment dropout occurred, and 2) identify predictors of dropout from a concurrent treatment for PTSD and SUD. Participants were 51 male and female veterans diagnosed with current PTSD and SUD. All participants completed at least one session of a cognitive-behavioral treatment (COPE) designed to simultaneously address PTSD and SUD symptoms. Of the 51 participants, 22 (43.1%) dropped out of treatment prior to completing the full 12 session COPE protocol. Results indicated that the majority of dropout (55%) occurred after session 6, with the largest amount of dropout occurring between sessions 9 and 10. Results also indicated a marginally significant relationship between greater baseline PTSD symptom severity and premature dropout. These findings highlight inconsistencies related to timing and predictors of dropout, as well as the dearth of information noted about treatment dropout within PTSD and SUD literature. Suggestions for procedural changes, such as implementing continual symptom assessments during treatment and increasing dialog between provider and patient about dropout were made with the hopes of increasing consistency of findings and eventually reducing treatment dropout.
The study of psychosocial treatments for posttraumatic stress disorder (PTSD) has improved dramatically in the past decade, with greater rigor, expansion of sampling, and diverse treatment models. At this point it is clear that PTSD treatments work better than treatment as usual; average effect sizes are in the moderate to high range; a variety of treatments are established as effective, with no one treatment having superiority; and both present-focused and past-focused models work (neither outperforms the other). Areas of future direction include the need to better understand therapist training, treatment dissemination, patient access to care; optimal treatment delivery, and mechanisms of action. Methodological issues are also discussed.
Objective:
The present study examined predictors and moderators of dropout among 165 adults meeting DSM-IV criteria for posttraumatic stress disorder (PTSD) and alcohol dependence (AD). Participants were randomized to 24 weeks of naltrexone (NAL), NAL and prolonged exposure (PE), pill placebo, or pill placebo and PE. All participants received supportive AD counseling (the BRENDA manualized model).
Method:
Logistic regression using the Fournier approach was conducted to investigate baseline predictors of dropout across the entire study sample. Rates of PTSD and AD symptom improvement were included to evaluate the impact of symptom change on dropout.
Results:
Trauma type and rates of PTSD and AD improvement significantly predicted dropout, accounting for 76% of the variance in dropout. Accidents and "other" trauma were associated with the highest dropout, and physical assault was associated with the lowest dropout. For participants with low baseline PTSD severity, faster PTSD improvement predicted higher dropout. For those with high baseline severity, both very fast and very slow rates of PTSD improvement were associated with higher dropout. Faster rates of drinking improvement predicted higher dropout among participants who received PE.
Conclusions:
The current study highlights the influence of symptom trajectory on dropout risk. Clinicians may improve retention in PTSD-AD treatments by monitoring symptom change at regular intervals, and eliciting patient feedback on these changes.
The experience of traumatic events is a near-universal, albeit unfortunate, part of the human experience. Given how many individuals are exposed to trauma, it is interesting to question why some individuals are resilient in the face of trauma while others go on to develop chronic post-traumatic stress. Throughout the relatively brief history of the psychological study of trauma, a number of themes have consistently emerged. Many of these themes remain essential elements within the current study of traumatic stress disorders, as summarized within this volume, which addresses the current landscape of research and clinical knowledge surrounding traumatic stress disorders. Bringing together a group of experts, the volume is divided into six sections, together summarizing the current state of knowledge about: classification and phenomenology; epidemiology and special populations; contributions from theory; assessment; prevention and early intervention efforts; and treatment of individuals with post-trauma mental health symptoms. Throughout the volume, attention is paid to identifying current controversies in the literature and highlighting directions that hold promise for future work.
Trauma-focused treatments are underutilized, partially due to clinician concerns that they will cause symptom exacerbation or dropout. We examined a sample of women undergoing Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and a version of CPT (CPT-C) without a written trauma narrative to investigate the possibility of symptom exacerbation. Participants (n = 192) were drawn from two RCT's. Participants were administered self-report measures of PTSD symptoms (i.e., the PTSD Symptom Scale or Posttraumatic Diagnostic Scale [PSS/PDS]) and the Clinician-Administered PTSD Scale. Exacerbations were defined as increases greater than 6.15 points on the PSS/PDS. A minority of participants experienced PTSD exacerbations during treatment, and there were no significant differences across treatment type (28.6% in CPT, 20.0% in PE, and 14.7% in CPT-C). Neither diagnostic nor trauma-related factors at pre-treatment predicted symptom exacerbations. Those who experienced exacerbations had higher post-treatment PSS/PDS scores and were more likely to retain a PTSD diagnosis (both small but statistically significant effects). However, even those who experienced an exacerbation experienced clinically significant improvement by end of treatment. Further, symptom exacerbations were not related to treatment non-completion. These results indicate that trauma-focused treatments are safe and effective, even for the minority of individuals who experience temporary symptom increases.
Cognitive Processing Therapy (CPT) has been recognized by the Institute of Medicine (2007) as one of the most effective treatments for PTSD. This chapter provides a brief overview of the CPT session content, the underlying mechanisms of the therapy, a review of the empirically based literature outlining the treatment effectiveness, limitations of the therapy, and areas of future research. In addition, the authors discuss the utility of the various versions of CPT, including cognitive only (CPT-C), group, individual, and combination. Further the research supporting the effectiveness of CPT for treating PTSD related to a variety of traumas, (e.g., combat, child abuse, and rape) and the significant impact CPT can have in areas of mental health related to PTSD (e.g., anger, guilt, social functioning) are described.
The Posttraumatic Stress Disorder Checklist (PCL) is a widely used DSM-correspondent self-report measure of PTSD symptoms. The PCL was recently revised to reflect DSM-5 changes to the PTSD criteria. In this article, the authors describe the development and initial psychometric evaluation of the PCL for DSM-5 (PCL-5). Psychometric properties of the PCL-5 were examined in 2 studies involving trauma-exposed college students. In Study 1 (N = 278), PCL-5 scores exhibited strong internal consistency (α = .94), test-retest reliability (r = .82), and convergent (rs = .74 to .85) and discriminant (rs = .31 to .60) validity. In addition, confirmatory factor analyses indicated adequate fit with the DSM-5 4-factor model, χ(2) (164) = 455.83, p < .001, standardized root mean square residual (SRMR) = .07, root mean squared error of approximation (RMSEA) = .08, comparative fit index (CFI) = .86, and Tucker-Lewis index (TLI) = .84, and superior fit with recently proposed 6-factor, χ(2) (164) = 318.37, p < .001, SRMR = .05, RMSEA = .06, CFI = .92, and TLI = .90, and 7-factor, χ(2) (164) = 291.32, p < .001, SRMR = .05, RMSEA = .06, CFI = .93, and TLI = .91, models. In Study 2 (N = 558), PCL-5 scores demonstrated similarly strong reliability and validity. Overall, results indicate that the PCL-5 is a psychometrically sound measure of PTSD symptoms. Implications for use of the PCL-5 in a variety of assessment contexts are discussed.
A significant number of veterans of the conflicts in Iraq and Afghanistan have posttraumatic stress disorder (PTSD), yet underutilization of mental health treatment remains a significant problem. The purpose of this review was to summarize rates of dropout from outpatient, psychosocial PTSD interventions provided to U.S. Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) veterans with combat-related PTSD. There were 788 articles that were identified which yielded 20 studies involving 1,191 individuals eligible for the review. The dropout rates in individual studies ranged from 5.0% to 78.2%, and the overall pooled dropout rate was 36%, 95% CI [26.20, 43.90]. The dropout rate differed marginally by study type (routine clinical care settings had higher dropout rates than clinical trials) and treatment format (group treatment had higher dropout rates than individual treatment), but not by whether comorbid substance dependence was excluded, by treatment modality (telemedicine vs. in-person treatment), or treatment type (exposure therapy vs. nonexposure therapy). Dropout is a critical aspect of the problem of underutilization of care among OEF/OIF/OND veterans with combat-related PTSD. Innovative strategies to enhance treatment retention are needed.
This study describes a one-group pretest posttest evaluation of an agency-based treatment for children who endured complex trauma, including chronic physical abuse, sexual abuse, neglect, and witnessing domestic violence. Participants included 31 children who completed at least 3 months of treatment at a private, child welfare treatment clinic. Treatment was phase-oriented and idiographic, grounded in attachment-based, cognitive-behavioral, and creative arts approaches to complex trauma treatment, and incorporating research-supported interventions. Children completed the Trauma Symptom Checklist for Children at pre- and post-treatment, and client change in symptoms was evaluated. Significant improvement in symptoms of anxiety, depression, anger, dissociation, and sexual concerns was found following treatment. Effect sizes were in the moderate to large range. Client demographic and clinical characteristics were not associated with symptom improvement. Though preliminary, due to the small sample size and lack of control group, results contribute to the growing body of knowledge on client outcomes in front line clinical settings.
Background:
Data were obtained on the general population epidemiology of DSM-III-R posttraumatic stress disorder (PTSD), including information on estimated lifetime prevalence, the kinds of traumas most often associated with PTSD, sociodemographic correlates, the comorbidity of PTSD with other lifetime psychiatric disorders, and the duration of an index episode.Methods:
Modified versions of the DSM-III-R PTSD module from the Diagnostic Interview Schedule and of the Composite International Diagnostic Interview were administered to a representative national sample of 5877 persons aged 15 to 54 years in the part II subsample of the National Comorbidity Survey.Results:
The estimated lifetime prevalence of PTSD is 7.8%. Prevalence is elevated among women and the previously married. The traumas most commonly associated with PTSD are combat exposure and witnessing among men and rape and sexual molestation among women. Posttraumatic stress disorder is strongly comorbid with other lifetime DSM-III-R disorders. Survival analysis shows that more than one third of people with an index episode of PTSD fail to recover even after many years.Conclusions:
Posttraumatic stress disorder is more prevalent than previously believed, and is often persistent. Progress in estimating age-at-onset distributions, cohort effects, and the conditional probabilities of PTSD from different types of trauma will require future epidemiologic studies to assess PTSD for all lifetime traumas rather than for only a small number of retrospectively reported "most serious" traumas.
The paper describes an empirically-based group therapy model for adult survivors of childhood incest. Process as well as outcome data based on a sample of 53 women are reported. The findings suggest that group intervention did help reduce depression and improve self-assessment. Follow-up data on levels of depression show that gains at termination were maintained at least six months post-intervention. Further monitoring, testing and fine-tuning of the model is still necessary.
In a series of 51 previously abused women who entered therapy, 92% were found to have at least one form of mood disturbance such as low self-esteem, feelings of guilt, and depressive episodes. It is hypothesized that these disturbances may arise from certain distorted beliefs that clients hold concerning their earlier sexual abuse. Some common self-blaming and self-denigratory beliefs are outlined. An intervention package that included cognitive restructuring procedures was accompanied by clinically and statistically significant improvements in the clients' belief systems and the associated mood disturbances.
Many women who seek help from psychologists, psychiatrists, social workers, counsellors and nurses, have been sexually abused in childhood. These women frequently complain of a wide range of mood disturbances, interpersonal difficulties and sexual dysfunctions that appear to be related to their earlier abuse and its surrounding circumstances. Consequently these contributory factors often need to be addressed in therapy.
This book offers a systematic and comprehensive approach to the assessment and treatment of the psychosocial problems that are commonly encountered in this client group. These problems are described, and detailed guidelines are provided for practitioners who wish to implement and develop the author's intervention package. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Posttraumatic stress disorder (PTSD) is a well recognized reaction to traumatic events, such as assault, disasters, and severe accidents. The symptoms include involuntary reexperiencing of aspects of the event, hyperarousal, emotional numbing, and avoidance of stimuli that could serve as reminders of the event. Many people experience at least some of these symptoms in the immediate aftermath of a traumatic event. A large proportion recover in the ensuing months or years, but in a significant subgroup the symptoms persist, often for many years (Ehlers, Mayou, & Bryant, 1998; Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). This raises the question of why PTSD persists in some individuals and how the condition can be treated. The present chapter overviews our group's cognitive approach to these questions. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Research on the predictors of response to cognitive-behavioral treatments for PTSD has often produced inconsistent or ambiguous results. We argue this is in part due to the use of statistical techniques that explore relationships among the entire sample of participants rather than homogeneous subgroups. Using 2 large randomized controlled trials of Cognitive Processing Therapy (CPT), CPT components, and Prolonged Exposure, we employed growth mixture modeling to identify distinct trajectories of treatment response and to determine the predictors of those trajectories. We determined that the participants' trajectories could be best represented by 2 latent classes, which we subsequently labeled responders (87% of the sample) and nonresponders (13% of the sample). Notably, there was not a separate class for partial responders. Assignment to the nonresponder class was associated with receiving the written accounts (WA) component of CPT, a pretreatment diagnosis of major depression (MDD), and more pretreatment hyperarousal symptoms. Thus, it appears that some individuals do not benefit from merely writing about their trauma and processing it with the therapist; they may also need to engage in cognitive restructuring to successfully ameliorate their symptoms. Additionally, those who meet criteria for MDD or have high levels of hyperarousal at the onset of treatment might require additional treatment or support.
Considerable evidence exists for the efficacy and tolerability of exposure therapy for PTSD (cf. Foa & Rothbaum, 1998; Rothbaum, Meadows, Resick, & Foy, 2000). However, the use of exposure therapy in real-world settings has lagged behind such findings. It is our belief that this gap between science and practice is partly due to several clinical myths regarding the use of exposure therapy. In this article, we outline four such myths, discuss relevant empirical findings, and argue that exposure therapy is indeed applicable for the treatment of a variety of patients with PTSD by clinicians in a variety of real-world settings.
Recent research has focused on the effectiveness of evidence-based psychotherapy delivered via telehealth services. Unfortunately to date, the majority of studies employ very small samples and limited predictor and moderator variables. To address these concerns and further replicate and extend the literature on telehealth, the present study investigated the effectiveness of 12-session exposure therapy delivered either via telehealth (n=62) or in person (n=27) in veterans with posttraumatic stress disorder (PTSD). Findings demonstrated that although older veterans and Vietnam veterans were more likely to complete the telehealth treatment, telehealth findings were not influenced by patient age, sex, race, combat theater, or disability status. Exposure therapy delivered via telehealth was effective in reducing the symptoms of PTSD, anxiety, depression, stress, and general impairment with large effect sizes. Interestingly, exposure therapy via telehealth was less effective than exposure therapy delivered in person; however, lack of random assignment to condition limits conclusions of differential effectiveness. Overall, these findings support the utility of telehealth services to provide effective, evidence-based psychotherapies.
To investigate when and why therapists opt for or rule out imaginal exposure (IE) for patients with posttraumatic stress disorder (PTSD), 255 trauma experts were randomized to two conditions in which they were presented with four cases in which the patients' comorbidity and treatment preferences were manipulated. The results confirmed IE to be an underutilized approach, with the majority of professionals being undertrained in the technique. As predicted, the patient factors influenced the expert's choice of therapy: in case of a comorbid depression, IE was significantly less preferred than medication. Also, IE was significantly more likely to be offered when patients expressed a preference for trauma-focused treatment. The therapist factors were also found to be importantly related to treatment preferences, with high credibility in the technique being positively related to the therapists' preference for IE. Perceived barriers to IE, such as a fear of symptom exacerbation and dropout, were negatively related to the perceived suitability of the treatment when patients had suffered multiple traumas in childhood. The results are discussed in the light of clinical implications and the need of exposure training for trauma professionals.
The Life Events Checklist (LEC), a measure of exposure to potentially traumatic events, was developed at the National Center for Posttraumatic Stress Disorder (PTSD) concurrently with the Clinician Administered PTSD Scale (CAPS) to facilitate the diagnosis of PTSD. Although the CAPS is recognized as the gold standard in PTSD symptom assessment, the psychometric soundness of the LEC has never been formally evaluated. The studies reported here describe the performance of the LEC in two samples: college undergraduates and combat veterans. The LEC exhibited adequate temporal stability, good convergence with an established measure of trauma history -- the Traumatic Life Events Questionnaire (TLEQ) -- and was comparable to the TLEQ in associations with variables known to be correlated with traumatic exposure in a sample of undergraduates. In a clinical sample of combat veterans, the LEC was significantly correlated, in the predicted directions, with measures of psychological distress and was strongly associated with PTSD symptoms.