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Ghafoori B, Wolf MG, Nylund-Gibson K, Felix ED. A naturalistic study exploring mental health outcomes following trauma-focused treatment among diverse survivors of crime and violence. J Affect Disord 2019; 245:617-625. [PMID: 30445387 DOI: 10.1016/j.jad.2018.11.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 09/23/2018] [Accepted: 11/03/2018] [Indexed: 11/29/2022]
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.
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Affiliation(s)
- Bita Ghafoori
- California State University, Department of Advanced Studies in Education and Counseling, Long Beach, 1250 Bellflower Boulevard, Long Beach, CA 90840-2201, United States.
| | | | | | - Erika D Felix
- University of California, Santa Barbara, CA, United States
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52
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Impact of Borderline Personality Pathology on Treatment Outcomes in Adolescents in Residential Treatment: The Role of Emotion Regulation. J Psychiatr Pract 2018; 24:388-398. [PMID: 30395546 DOI: 10.1097/pra.0000000000000349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Despite growing research on the impact of borderline personality pathology (BPP) on treatment outcomes for emotional disorders among adults, no studies have examined this question in adolescents. Moreover, no studies have examined mediators of the relation between BPP and changes in mood and anxiety symptoms during treatment. This study examined the impact of BPP on treatment outcomes in 141 adolescents in psychiatric residential treatment, as well as the mediating role of change in emotion regulation (ie, adaptive responses to emotions) in the relation between baseline BPP and improvements in psychiatric symptoms during treatment. Participants completed questionnaires assessing emotion regulation and depression, anxiety, and posttraumatic stress disorder symptoms at baseline and posttreatment. Although BPP was not directly associated with the magnitude of change in psychiatric symptoms from baseline to posttreatment, it was positively associated with greater improvement in emotion regulation during treatment. Furthermore, results revealed significant indirect effects of BPP on improvements in all psychiatric symptoms through improvement in emotion regulation.
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53
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Alberici A, Meiser-Stedman R, Claxton J, Smith P, Ehlers A, Dixon C, Mckinnon A. The Preliminary Development and Validation of a Trauma-Related Safety-Seeking Behavior Measure for Youth: The Child Safety Behavior Scale (CSBS). J Trauma Stress 2018; 31:643-653. [PMID: 30338580 DOI: 10.1002/jts.22332] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 07/07/2018] [Accepted: 07/11/2018] [Indexed: 11/10/2022]
Abstract
Safety-seeking behaviors (SSBs) may be employed after exposure to a traumatic event in an effort to prevent a feared outcome. Cognitive models of posttraumatic stress disorder propose SSBs contribute to maintaining this disorder by preventing disconfirmation of maladaptive beliefs and preserving a sense of current threat. Recent research has found that SSBs impact children's posttraumatic stress symptoms (PTSS) and recovery. In this paper, we sought to develop and validate a novel 22-item Child Safety Behavior Scale (CSBS) in a school-based sample of 391 pupils (age 12-15 years) who completed a battery of questionnaires as well as 68 youths (age 8-17 years) who were recently exposed to a trauma. Of the sample, 93.1% (N = 426) completed the new questionnaire. The sample was split (n = 213), and we utilized principal components analysis alongside parallel analysis, which revealed that 13 items loaded well onto a two-factor structure. This structure was superior to a one-factor model and overall demonstrated a moderately good model of fit across indices, based upon a confirmatory factory analysis with the other half of the sample. The CSBS showed excellent internal consistency, r = .90; good test-retest reliability, r = .64; and good discriminant validity and specificity. In a multiple linear regression, SSBs, negative appraisals, and number of trauma types each accounted for unique variance in a model of PTSS. This study provides initial support for the use of the CSBS in trauma-exposed youth as a valuable tool for further research, clinical assessment, and targeted intervention.
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Affiliation(s)
- Alice Alberici
- Community Child and Adolescent Mental Health Services, Chichester, West Sussex, United Kingdom
| | - Richard Meiser-Stedman
- Department of Clinical Psychology, University of East Anglia, Norwich Medical School, Norwich, United Kingdom
| | - Jade Claxton
- Community Child and Adolescent Mental Health Services, Mary Chapman House, Hotblack road, Norwich, United Kingdom
| | - Patrick Smith
- Department of Psychology, King's College London, Inst. of Psychiatry, Denmark Hill, United Kingdom
| | - Anke Ehlers
- Oxford Centre for Anxiety Disorders and Trauma, University of Oxford, Oxford, United Kingdom
| | - Clare Dixon
- Community Child and Adolescent Mental Health Services, Horsham, West Sussex, United Kingdom
| | - Anna Mckinnon
- Centre for Emotional Health, Macquarie University, Sydney, New South Wales, Australia
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54
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Monson CM, Shields N, Suvak MK, Lane JEM, Shnaider P, Landy MSH, Wagner AC, Sijercic I, Masina T, Wanklyn SG, Stirman SW. A randomized controlled effectiveness trial of training strategies in cognitive processing therapy for posttraumatic stress disorder: Impact on patient outcomes. Behav Res Ther 2018; 110:31-40. [PMID: 30218837 DOI: 10.1016/j.brat.2018.08.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 06/18/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022]
Abstract
This randomized controlled hybrid implementation/effectiveness trial aimed to compare the impact of three different models of training and consultation by examining the PTSD treatment outcomes achieved by therapists who were learning a front-line recommended psychotherapy for posttraumatic stress disorder (PTSD), Cognitive Processing Therapy (CPT; Resick, Monson, & Chard, 2017). Therapists (N = 134) were randomized into one of three conditions after attending a standard CPT training workshop: No Consultation with delayed feedback on CPT fidelity, Standard Consultation involving discussion and conceptualization of cases without session audio review, and Consultation Including Audio Review, which included a review of segments of audiorecorded CPT sessions. Across all training conditions, the patients treated by these therapists (N = 188) evidenced statistically significant reductions in PTSD symptoms, (d = -0.95 to -1.78), comorbid symptoms and functioning (d = -0.27 to -0.51). However, patients of therapists in the Standard Consultation condition (ΔPTSD = - 19.64, d = -1.78) experienced significantly greater improvement than those in the No Consultation condition (ΔPTSD = - 10.54, d = -0.95, ΔDEV = 6.30, ΔParms = 2, p = .043). This study demonstrates that patients who receive evidence-based psychotherapy for PTSD in routine care settings can experience significant symptom improvement. Our findings also suggest that to maximize patient benefit, therapist training should include consultation, but that audio review of sessions during consultation may not be necessary, at least for structured protocols. Implications for implementation, including the reduction of burden and cost of post-workshop support, are discussed.
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Affiliation(s)
- Candice M Monson
- Department of Psychology, Ryerson University, 350 Victoria St., Toronto, Ontario, M5B 2K3, Canada
| | - Norman Shields
- Veterans Affairs Canada Place, 800 Dela Gauchetiere Street, West Montreal, Quebec, Canada
| | - Michael K Suvak
- Department of Psychology, Suffolk University, 73 Tremont Street, Boston, MA, 02108, USA
| | - Jeanine E M Lane
- Department of Psychology, Ryerson University, 350 Victoria St., Toronto, Ontario, M5B 2K3, Canada
| | - Philippe Shnaider
- Department of Psychology, Ryerson University, 350 Victoria St., Toronto, Ontario, M5B 2K3, Canada; Anxiety Research and Treatment Centre, St. Joseph's Healthcare, 100 West 5th Street, Hamilton, Ontario, L8N 3K7, Canada
| | - Meredith S H Landy
- Department of Psychology, Ryerson University, 350 Victoria St., Toronto, Ontario, M5B 2K3, Canada
| | - Anne C Wagner
- Department of Psychology, Ryerson University, 350 Victoria St., Toronto, Ontario, M5B 2K3, Canada
| | - Iris Sijercic
- Department of Psychology, Ryerson University, 350 Victoria St., Toronto, Ontario, M5B 2K3, Canada
| | - Tasoula Masina
- Department of Psychology, Ryerson University, 350 Victoria St., Toronto, Ontario, M5B 2K3, Canada
| | - Sonya G Wanklyn
- Department of Psychology, Ryerson University, 350 Victoria St., Toronto, Ontario, M5B 2K3, Canada
| | - Shannon Wiltsey Stirman
- National Center for PTSD, VA Palo Alto Healthcare System, 795 Willow Road (NC-PTSD), Menlo Park, CA, 94025, USA; Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Road, Stanford, CA, 94305, USA.
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Pereira JA, Barkham M, Kellett S, Saxon D. The Role of Practitioner Resilience and Mindfulness in Effective Practice: A Practice-Based Feasibility Study. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2018; 44:691-704. [PMID: 27424107 PMCID: PMC5550533 DOI: 10.1007/s10488-016-0747-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A growing body of literature attests to the existence of therapist effects with little explanation of this phenomenon. This study therefore investigated the role of resilience and mindfulness as factors related to practitioner wellbeing and associated effective practice. Data comprised practitioners (n = 37) and their patient outcome data (n = 4980) conducted within a stepped care model of service delivery. Analyses employed benchmarking and multilevel modeling to identify more and less effective practitioners via yoking of therapist factors and nested patient outcomes. A therapist effect of 6.7 % was identified based on patient depression (PHQ-9) outcome scores. More effective practitioners compared to less effective practitioners displayed significantly higher levels of mindfulness as well as resilience and mindfulness combined. Implications for policy, research and practice are discussed.
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Affiliation(s)
- Jo-Ann Pereira
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - Michael Barkham
- Centre for Psychological Services Research, Department of Psychology, University of Sheffield, Sheffield, UK
| | - Stephen Kellett
- Centre for Psychological Services Research, Department of Psychology, University of Sheffield; Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
| | - David Saxon
- Centre for Psychological Services Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
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56
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Remission in CBT for adult anxiety disorders: A meta-analysis. Clin Psychol Rev 2018; 61:1-8. [DOI: 10.1016/j.cpr.2018.03.002] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 03/14/2018] [Accepted: 03/14/2018] [Indexed: 11/23/2022]
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Hendriks L, de Kleine RA, Broekman TG, Hendriks GJ, van Minnen A. Intensive prolonged exposure therapy for chronic PTSD patients following multiple trauma and multiple treatment attempts. Eur J Psychotraumatol 2018; 9:1425574. [PMID: 29410776 PMCID: PMC5795659 DOI: 10.1080/20008198.2018.1425574] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 12/23/2017] [Indexed: 11/15/2022] Open
Abstract
Background: Suboptimal response and high dropout rates leave room for improvement of trauma-focused treatment (TFT) effectiveness in ameliorating posttraumatic stress disorder (PTSD) symptoms. Objective: To explore the effectiveness and safety of intensive prolonged exposure (iPE) targeting chronic PTSD patients with a likely diagnosis of ICD-11 Complex PTSD following multiple interpersonal trauma and a history of multiple treatment attempts. Method: Participants (N = 73) received iPE in 12 × 90-minute sessions over four days (intensive phase) followed by four weekly 90-minute booster prolonged exposure (PE) sessions (booster phase). The primary outcomes, clinician-rated severity of PTSD symptoms, and diagnostic status (Clinician-Administered PTSD Scale; CAPS-IV) were assessed at baseline, post-treatment, and at three and six months. Treatment response trajectories were identified and predictors of these trajectories explored. Results: Mixed model repeated measures analysis of CAPS-IV scores showed a baseline-to-posttreatment decrease in PTSD symptom severity (p < .001) that persisted during the three- and six-month follow-ups with large effect sizes (Cohen's d > 1.2); 71% of the participants responded. None of the participants dropped out during the intensive phase and only 5% during the booster phase. Adverse events were extremely low and only a minority showed symptom exacerbation. Cluster analysis demonstrated four treatment response trajectories: Fast responders (13%), Slow responders (26%), Partial responders (32%), and Non-responders (29%). Living condition and between-session fear habituation were found to predict outcome. Participants living alone were more likely to belong to the Partial responders than to the Non-responders cluster, and participants showing more between-session fear habituation were more likely to belong to the Fast responders than to the Non-responders cluster. Conclusions: The results of this open study suggest that iPE can be effective in PTSD patients with multiple interpersonal trauma and after multiple previous treatment attempts. In addition, in this chronic PTSD population iPE was safe.
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Affiliation(s)
- Lotte Hendriks
- Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands.,Behavioural Science Institute, NijCare, Radboud University, Nijmegen, The Netherlands
| | - Rianne A de Kleine
- Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands., Institute of Psychology, Leiden University, Leiden, The Netherlands
| | | | - Gert-Jan Hendriks
- Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands.,Behavioural Science Institute, NijCare, Radboud University, Nijmegen, The Netherlands.,Department of Psychiatry, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Agnes van Minnen
- Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands.,Behavioural Science Institute, NijCare, Radboud University, Nijmegen, The Netherlands.,Psychotrauma Expertise Centre (PSYTREC), Bilthoven, The Netherlands
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58
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Intensive cognitive therapy for post-traumatic stress disorder in routine clinical practice: A matched comparison audit. BRITISH JOURNAL OF CLINICAL PSYCHOLOGY 2017; 56:474-478. [DOI: 10.1111/bjc.12150] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/01/2017] [Indexed: 12/01/2022]
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Abstract
Background: Post-traumatic stress disorder (PTSD) is a highly prevalent and impairing condition for which there are several evidence-based psychotherapies. However, a significant proportion of patients fail to complete a ‘sufficient dose’ of psychotherapy, potentially limiting treatment gains. Aims: The present study investigated predictors of premature treatment discontinuation during a trial of prolonged exposure (PE) therapy for PTSD. Method: Combat veterans with PTSD were recruited to participate in a randomized clinical trial of PE delivered in person or via telehealth technologies. Of the 150 initial participants, 61 participants discontinued the trial before the completion of eight sessions (of an 8‒12 session protocol). Treatment condition (telehealth or in person) and factors identified by prior research (age, combat theatre, social support, PTSD symptoms) were tested as predictors of treatment discontinuation. Results: A Cox proportional hazards model (a subtype of survival analysis) was used to evaluate predictors of treatment discontinuation. Disability status and treatment condition were identified as significant predictors of discontinuation, with a noted disability and use of telehealth demonstrating higher risk. Conclusions: The present findings highlight the influence of telehealth and disability status on treatment discontinuation, while minimizing the role of the previously identified variables from studies with less sensitive analyses.
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60
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Holder N, Holliday R, Pai A, Surís A. Role of Borderline Personality Disorder in the Treatment of Military Sexual Trauma-related Posttraumatic Stress Disorder with Cognitive Processing Therapy. Behav Med 2017; 43:184-190. [PMID: 28767012 DOI: 10.1080/08964289.2016.1276430] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cognitive Processing Therapy (CPT) is an effective evidence-based treatment for many, but not all, veterans with posttraumatic stress disorder (PTSD). Understanding the factors that contribute to poorer response to CPT is important for providing the best care to veterans diagnosed with PTSD. Researchers investigating the effectiveness of CPT for individuals with comorbid personality symptoms have found that borderline personality disorder (BPD) characteristics do not negatively affect treatment outcome; however, participants in those studies were not diagnosed with BPD. The current pilot study investigated the effect of a BPD diagnosis on CPT dropout and outcomes. Data were compiled from a larger randomized clinical trial. Twenty-seven female veterans with military sexual trauma-related PTSD received CPT. Dropout was evaluated by treatment completion and number of sessions attended. Treatment outcome was assessed by the Clinician Administered PTSD Scale (CAPS) and the PTSD Checklist (PCL). No significant differences were observed between veterans with and without BPD comorbidity for number of treatment sessions attended, and there was not a significant relationship between comorbidity status and treatment completion. A hierarchical linear modeling approach was used with BPD entered as a level 2 predictor of outcome. In our sample, veterans with BPD had higher PTSD symptom severity on the CAPS at baseline compared to veterans without BPD comorbidity. CPT was effective in reducing PTSD symptoms; however, BPD diagnosis did not influence treatment response over time on the CAPS or PCL. Our results provide initial support for the use of CPT in female veterans with MST-related PTSD and comorbid BPD.
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Affiliation(s)
- Nicholas Holder
- a Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center
| | - Ryan Holliday
- a Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center
| | - Anushka Pai
- a Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center
| | - Alina Surís
- a Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center
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61
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Szafranski DD, Smith BN, Gros DF, Resick PA. High rates of PTSD treatment dropout: A possible red herring? J Anxiety Disord 2017; 47:91-98. [PMID: 28117192 DOI: 10.1016/j.janxdis.2017.01.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 11/23/2016] [Accepted: 01/05/2017] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Derek D Szafranski
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, United States.
| | - Brian N Smith
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, United States; Department of Psychiatry, Boston University School of Medicine, Boston, MA, United States.
| | - Daniel F Gros
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, United States; Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States.
| | - Patricia A Resick
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, United States.
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Wiltsey Stirman S, Finley EP, Shields N, Cook J, Haine-Schlagel R, Burgess JF, Dimeff L, Koerner K, Suvak M, Gutner CA, Gagnon D, Masina T, Beristianos M, Mallard K, Ramirez V, Monson C. Improving and sustaining delivery of CPT for PTSD in mental health systems: a cluster randomized trial. Implement Sci 2017; 12:32. [PMID: 28264720 PMCID: PMC5339953 DOI: 10.1186/s13012-017-0544-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 01/28/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Large-scale implementation of evidence-based psychotherapies (EBPs) such as cognitive processing therapy (CPT) for posttraumatic stress disorder can have a tremendous impact on mental and physical health, healthcare utilization, and quality of life. While many mental health systems (MHS) have invested heavily in programs to implement EBPs, few eligible patients receive EBPs in routine care settings, and clinicians do not appear to deliver the full treatment protocol to many of their patients. Emerging evidence suggests that when CPT and other EBPs are delivered at low levels of fidelity, clinical outcomes are negatively impacted. Thus, identifying strategies to improve and sustain the delivery of CPT and other EBPs is critical. Existing literature has suggested two competing strategies to promote sustainability. One emphasizes fidelity to the treatment protocol through ongoing consultation and fidelity monitoring. The other focuses on improving the fit and effectiveness of these treatments through appropriate adaptations to the treatment or the clinical setting through a process of data-driven, continuous quality improvement. Neither has been evaluated in terms of impact on sustained implementation. METHODS To compare these approaches on the key sustainability outcomes and provide initial guidance on sustainability strategies, we propose a cluster randomized trial with mental health clinics (n = 32) in three diverse MHSs that have implemented CPT. Cohorts of clinicians and clinical managers will participate in 1 year of a fidelity oriented learning collaborative or 1 year of a continuous quality improvement-oriented learning collaborative. Patient-level PTSD symptom change, CPT fidelity and adaptation, penetration, and clinics' capacity to deliver EBP will be examined. Survey and interview data will also be collected to investigate multilevel influences on the success of the two learning collaborative strategies. This research will be conducted by a team of investigators with expertise in CPT implementation, mixed method research strategies, quality improvement, and implementation science, with input from stakeholders in each participating MHS. DISCUSSION It will have broad implications for supporting ongoing delivery of EBPs in mental health and healthcare systems and settings. The resulting products have the potential to significantly improve efforts to ensure ongoing high quality implementation and consumer access to EBPs. TRIAL REGISTRATION NCT02449421 . Registered 02/09/2015.
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Affiliation(s)
- Shannon Wiltsey Stirman
- National Center for PTSD and Stanford University Department of Psychiatry and Behavioral Sciences, 795 Willow Road, Menlo Park, CA 94025 USA
| | - Erin P. Finley
- The University of Texas Health Science Center at San Antonio, Department of Psychiatry and Medicine, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA
- South Texas Veterans Health Care System, 7400 Merton Minter St, San Antonio, TX 78229 USA
| | - Norman Shields
- Divisional Psychologist Occupational Health and Safety, Royal Canadian Mounted Police, 4225 Dorchester, Westmount, QC Canada
| | - Joan Cook
- Department of Psychiatry, Yale University, 950 Campbell Avenue, West Haven, CT 06516 USA
| | | | - James F. Burgess
- Boston University School of Public Health, Department of Health Law, Policy and Management, Boston, MA 02215 USA
- Center for Healthcare Organization and Implementation Research (CHOIR), Department of Veterans Affairs Boston Healthcare System, Boston, MA USA
| | - Linda Dimeff
- Evidence-Based Practice Institute, 3303 S Irving Street Seattle, Seattle, WA 91844 USA
| | - Kelly Koerner
- Evidence-Based Practice Institute, 3303 S Irving Street Seattle, Seattle, WA 91844 USA
| | - Michael Suvak
- Suffolk University, 73 Tremont Street, Boston, MA 01331 USA
| | - Cassidy A. Gutner
- National Center for PTSD, VA Boston Healthcare System, 150 S. Huntington Ave, Boston, MA 02130 USA
- Boston University School of Medicine, 72 E Concord St, Boston, MA 02118 USA
| | - David Gagnon
- Boston University School of Public Health, Department of Health Law, Policy and Management, Boston, MA 02215 USA
| | - Tasoula Masina
- Ryerson University, 350 Victoria Street, Toronto, ON M5B 2K3 Canada
| | - Matthew Beristianos
- National Center for PTSD and Palo Alto Veterans Institute of Research, 795 Willow Road, Menlo Park, CA 94025 USA
| | - Kera Mallard
- National Center for PTSD and Palo Alto Veterans Institute of Research, 795 Willow Road, Menlo Park, CA 94025 USA
| | - Vanessa Ramirez
- The University of Texas Health Science Center at San Antonio, Department of Psychiatry and Medicine, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA
- South Texas Veterans Health Care System, 7400 Merton Minter St, San Antonio, TX 78229 USA
| | - Candice Monson
- Ryerson University, 350 Victoria Street, Toronto, ON M5B 2K3 Canada
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Prolonged exposure therapy for the treatment of patients diagnosed with psychogenic non-epileptic seizures (PNES) and post-traumatic stress disorder (PTSD). Epilepsy Behav 2017; 66:86-92. [PMID: 28038392 DOI: 10.1016/j.yebeh.2016.10.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/14/2016] [Accepted: 10/14/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Although there is general consensus that psychogenic non-epileptic seizures (PNES) are treated with psychotherapy, the effectiveness of most psychotherapeutic modalities remains understudied. In this treatment series of 16 patients dually diagnosed with PNES and post-traumatic stress disorder (PTSD), we evaluated the effect of prolonged exposure therapy (PE) on reduction of PNES. Secondary measures included Beck Depression Inventory (BDI-II) and Post-Traumatic Disorder Diagnostic Scale (PDS). METHODS Subjects diagnosed with video EEG-confirmed PNES and PTSD confirmed through neuropsychological testing and clinical interview were treated with traditional PE psychotherapy with certain modifications for the PNES. Treatment was conducted over the course of 12-15 weekly sessions. Seizure frequency was noted in each session by examining the patients' seizure logs, and mood and PTSD symptomatology was assessed at baseline and on the final session. RESULTS Eighteen subjects enrolled, and 16 (88.8%) completed the course of treatment. Thirteen of the 16 (81.25%) therapy completers reported no seizures by their final PE session, and the other three reported a decline in seizure frequency (Z=-3.233, p=0.001). Mean scores on scales of depression (M=-13.56, SD=12.27; t (15)=-4.420, p<0,001) and PTSD symptoms (M=-17.1875, SD=13.01; t (15)=-5.281, p<0.001) showed significant improvement from baseline to final session. Longitudinal seizure follow up in 14 patients revealed that gains made on the final session were maintained at follow-up (Z=-1.069 p=0.285). SIGNIFICANCE Prolonged exposure therapy for patients dually diagnosed with PNES and PTSD reduced the number of PNES and improved mood and post traumatic symptomatology. Follow-up revealed that gains made in seizure control on the last day of treatment were maintained over time.
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64
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Evidence-based training in the era of evidence-based practice: Challenges and opportunities for training of PTSD providers. Behav Res Ther 2017; 88:37-48. [DOI: 10.1016/j.brat.2016.07.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/24/2016] [Accepted: 07/26/2016] [Indexed: 11/22/2022]
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Lau C, Hebert M, Vani MA, Walling S, Hayley S, Lagace DC, Blundell J. Absence of neurogenic response following robust predator-induced stress response. Neuroscience 2016; 339:276-286. [DOI: 10.1016/j.neuroscience.2016.10.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 09/23/2016] [Accepted: 10/02/2016] [Indexed: 12/27/2022]
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Mills KL, Barrett EL, Merz S, Rosenfeld J, Ewer PL, Sannibale C, Baker AL, Hopwood S, Back SE, Brady KT, Teesson M. Integrated Exposure-Based Therapy for Co-Occurring Post Traumatic Stress Disorder (PTSD) and Substance Dependence: Predictors of Change in PTSD Symptom Severity. J Clin Med 2016; 5:jcm5110101. [PMID: 27854264 PMCID: PMC5126798 DOI: 10.3390/jcm5110101] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/26/2016] [Accepted: 11/08/2016] [Indexed: 11/26/2022] Open
Abstract
This paper examines factors associated with change in PTSD symptom severity among individuals randomised to receive an integrated exposure-based psychotherapy for PTSD and substance dependence–Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE). Outcomes examined include change in PTSD symptom severity as measured by the Clinician Administered PTSD Scale (CAPS), and the reliability and clinical significance of change in PTSD symptom severity. Factors examined include patient baseline characteristics, treatment characteristics, and events over follow-up. The mean difference in CAPS score was 38.24 (SE 4.81). Approximately half (49.1%) demonstrated a reliable and clinically significant improvement in PTSD symptom severity. No one was classified as having demonstrated clinically significant worsening of symptoms. Three independent predictors of reductions in PTSD symptom severity were identified: baseline PTSD symptom severity (β 0.77, SE 0.23, p = 0.001), number of traumas experienced prior to baseline (β −0.30, SE 0.15, p = 0.049), and number of sessions attended (β 2.05, SE 0.87, p = 0.024). The present study provides further evidence regarding the safety of the COPE treatment and factors associated with improvement in PTSD symptom severity. The identification of only a small number of predictors of the outcome points to the broad applicability of the COPE treatment to PTSD and substance use disorder (SUD) patients.
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Affiliation(s)
- Katherine L Mills
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney 2052, NSW, Australia.
- Centre of Research Excellence in Mental Health and Substance Use, University of New South Wales, Sydney 2052, NSW, Australia.
| | - Emma L Barrett
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney 2052, NSW, Australia.
- Centre of Research Excellence in Mental Health and Substance Use, University of New South Wales, Sydney 2052, NSW, Australia.
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA.
| | - Sabine Merz
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney 2052, NSW, Australia.
| | - Julia Rosenfeld
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney 2052, NSW, Australia.
| | - Philippa L Ewer
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney 2052, NSW, Australia.
- Centre of Research Excellence in Mental Health and Substance Use, University of New South Wales, Sydney 2052, NSW, Australia.
| | - Claudia Sannibale
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney 2052, NSW, Australia.
| | - Amanda L Baker
- School of Medicine and Public Health, University of Newcastle, Callaghan 2308, NSW, Australia.
| | - Sally Hopwood
- School of Psychology, University of New South Wales, Sydney 2052, NSW, Australia.
| | - Sudie E Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA.
| | - Kathleen T Brady
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA.
| | - Maree Teesson
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney 2052, NSW, Australia.
- Centre of Research Excellence in Mental Health and Substance Use, University of New South Wales, Sydney 2052, NSW, Australia.
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Wild J, Warnock-Parkes E, Grey N, Stott R, Wiedemann M, Canvin L, Rankin H, Shepherd E, Forkert A, Clark DM, Ehlers A. Internet-delivered cognitive therapy for PTSD: a development pilot series. Eur J Psychotraumatol 2016; 7:31019. [PMID: 27837579 PMCID: PMC5106866 DOI: 10.3402/ejpt.v7.31019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 07/05/2016] [Accepted: 07/27/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Randomised controlled trials have established that face-to-face cognitive therapy for posttraumatic stress disorder (CT-PTSD) based on Ehlers and Clark's cognitive model of PTSD is highly effective and feasible with low rates of dropout. Access to evidence-based psychological treatments for PTSD is insufficient. Several studies have shown that therapist-assisted treatment delivery over the Internet is a promising way of improving access to cognitive behavioural therapy interventions. OBJECTIVE To develop an Internet version of CT-PTSD that significantly reduces therapist contact time without compromising treatment integrity or retention rates. METHODS We describe the development of an Internet version of CT-PTSD. It implements all the key procedures of face-to-face CT-PTSD, including techniques that focus on the trauma memory, such as memory updating, stimulus discrimination and revisiting the trauma site, as well as restructuring individually relevant appraisals relating to overgeneralisation of danger, guilt, shame or anger, behavioural experiments and planning activities to reclaim quality of life. A cohort of 10 patients meeting DSM-IV criteria for PTSD worked through the programme, with remote guidance from a therapist, and they were assessed at pre- and post-treatment on PTSD outcome, mood, work and social adjustment and process measures. RESULTS No patients dropped out. Therapists facilitated the treatment with 192 min of contact time per patient, plus 57 min for reviewing the patient's progress and messages. Internet-delivered CT-PTSD was associated with very large improvements on all outcome and process measures, with 80% of patients achieving clinically significant change and remission from PTSD. CONCLUSIONS Internet-delivered cognitive therapy for PTSD (iCT-PTSD) appears to be an acceptable and efficacious treatment. Therapist time was reduced to less than 25% of time in face-to-face CT-PTSD. Randomised controlled trials are required to evaluate systematically the acceptability and efficacy of iCT-PTSD.
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Affiliation(s)
- Jennifer Wild
- Department of Experimental Psychology, University of Oxford, Oxford, UK
- Oxford NIHR Cognitive Health Clinical Research Facility, Oxford, UK;
| | - Emma Warnock-Parkes
- Department of Experimental Psychology, University of Oxford, Oxford, UK
- Oxford NIHR Cognitive Health Clinical Research Facility, Oxford, UK
- NIHR Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
| | - Nick Grey
- NIHR Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
| | - Richard Stott
- NIHR Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
| | - Milan Wiedemann
- Department of Experimental Psychology, University of Oxford, Oxford, UK
- Oxford NIHR Cognitive Health Clinical Research Facility, Oxford, UK
| | - Lauren Canvin
- Department of Experimental Psychology, University of Oxford, Oxford, UK
- Oxford NIHR Cognitive Health Clinical Research Facility, Oxford, UK
| | - Harriet Rankin
- NIHR Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
| | - Emma Shepherd
- Department of Experimental Psychology, University of Oxford, Oxford, UK
- Oxford NIHR Cognitive Health Clinical Research Facility, Oxford, UK
| | - Ava Forkert
- Department of Experimental Psychology, University of Oxford, Oxford, UK
- Oxford NIHR Cognitive Health Clinical Research Facility, Oxford, UK
| | - David M Clark
- Department of Experimental Psychology, University of Oxford, Oxford, UK
- Oxford NIHR Cognitive Health Clinical Research Facility, Oxford, UK
| | - Anke Ehlers
- Department of Experimental Psychology, University of Oxford, Oxford, UK
- Oxford NIHR Cognitive Health Clinical Research Facility, Oxford, UK
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Pilecki B, McKay D. Evidence-Based Therapies, Evidence-Based Practice, and the Intersection of Nomothetic and Idiographic Foundations of Psychotherapy Research and Application: A Reply to Shean. Psychodyn Psychiatry 2016; 44:25-38. [PMID: 26938798 DOI: 10.1521/pdps.2016.44.1.25] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This article is a commentary on "Psychotherapy Outcome Research: Issues and Questions" by Glenn Shean (this issue). While we agree with a couple of Shean's points, such as over-reliance on diagnoses and lack of attention to global measures of quality of life and functioning, there are several very substantive points of disagreement. We argue that evidence-based therapies and evidence-based practice occupy a central role in developing effective and non-harmful therapies. Shean conflates evidence-based therapies and evidence-based practice in a way that is not representative of how science is intended to advance everyday treatment delivery. We further contest Shean's notion that reliance on empirically based research is limiting to clinicians and instead argue that it offers a helpful and pragmatic starting point for clinical decision making with each unique patient. Further, evidence-based practice, in contrast to evidence-based therapies, represents the model ideal for service delivery, rather than a slavish adherence to protocols employed in randomized clinical trials. Finally, we argue that both nomothetic and idiographic approaches are valid and important in the ongoing advancement of modern psychotherapy, a position wholly consistent with the evidence-based practice movement.
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Affiliation(s)
- Brian Pilecki
- Rhode Island Hospital/Alpert Medical School of Brown University
| | - Dean McKay
- Rhode Island Hospital/Alpert Medical School of Brown University
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Schnyder U, Bryant RA, Ehlers A, Foa EB, Hasan A, Mwiti G, Kristensen CH, Neuner F, Oe M, Yule W. Culture-sensitive psychotraumatology. Eur J Psychotraumatol 2016; 7:31179. [PMID: 27473520 PMCID: PMC5055610 DOI: 10.3402/ejpt.v7.31179] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 06/13/2016] [Accepted: 06/27/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although there is some evidence of the posttraumatic stress disorder (PTSD) construct's cross cultural validity, trauma-related disorders may vary across cultures, and the same may be true for treatments that address such conditions. Experienced therapists tailor psychotherapy to each patient's particular situation, to the nature of the patient's psychopathology, to the stage of therapy, and so on. In addition, culture-sensitive psychotherapists try to understand how culture enhances the meaning of their patient's life history, the cultural components of their illness and help-seeking behaviors, as well as their expectations with regard to treatment. We cannot take for granted that all treatment-seeking trauma survivors speak our language or share our cultural values. Therefore, we need to increase our cultural competencies. METHODS The authors of this article are clinicians and/or researchers from across the globe, working with trauma survivors in various settings. Each author focused on one or more specific cultural aspects of working with trauma survivors and highlighted the following aspects. RESULTS As a result of culture-specific individual and collective meanings linked to trauma and trauma-related disorders survivors may be exposed to (self-)stigma in the aftermath of trauma. Patients who are reluctant to talk about their traumatic experiences may instead be willing to write or use other ways of accessing the painful memories such as drawing. In other cultures, community and family cohesion are crucial elements of recovery. While awareness of culture-specific aspects is important, we also need to beware of premature cultural stereotyping. When disseminating empirically supported psychotherapies for PTSD across cultures, a number of additional challenges need to be taken into account: many low and middle income countries have very limited resources available and suffer from a poor health infrastructure. CONCLUSIONS In summary, culture-sensitive psychotraumatology means assuming an empathic and non-judgmental attitude, trying to understand each individual's cultural background.
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Affiliation(s)
- Ulrich Schnyder
- Department of Psychiatry and Psychotherapy, University Hospital, University of Zurich, Zurich, Switzerland;
| | - Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Anke Ehlers
- Department of Experimental Psychology and Oxford Cognitive health NIHR Clinical Research Facility, University of Oxford, Oxford, UK
| | - Edna B Foa
- Department of Psychiatry, Center for the Treatment and Study of Anxiety, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Gladys Mwiti
- Oasis Africa Center for Transformational Psychology & Trauma, Nairobi, Kenya
| | - Christian H Kristensen
- Centre of Studies and Research in Traumatic Stress, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Frank Neuner
- Department of Clinical Psychology and Psychotherapy, Bielefeld University, Bielefeld, Germany
| | - Misari Oe
- Department of Neuropsychiatry, Kurume University School of Medicine, Fukuoka, Japan
| | - William Yule
- Department of Applied Child Psychology, King's College, London, UK
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Lommen MJJ, Grey N, Clark DM, Wild J, Stott R, Ehlers A. SLEEP AND TREATMENT OUTCOME IN POSTTRAUMATIC STRESS DISORDER: RESULTS FROM AN EFFECTIVENESS STUDY. Depress Anxiety 2016; 33:575-83. [PMID: 26393429 PMCID: PMC4934137 DOI: 10.1002/da.22420] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 08/05/2015] [Accepted: 08/16/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Most patients with posttraumatic stress disorder (PTSD) suffer from sleep problems. Concerns have been raised about possible detrimental effects of sleep problems on the efficacy of psychological treatments for PTSD. In this study, we investigated the relation of session-to-session changes in PTSD symptoms and sleep, and tested whether sleep problems predicted poorer short- and long-term treatment outcome. METHODS Self-reported sleep quality, sleep duration, and PTSD symptoms were assessed weekly in a consecutive sample of 246 patients who received cognitive therapy for PTSD (CT-PTSD; Ehlers & Clark, 2000), and at follow-up (mean = 247 days posttreatment). Additionally, moderating effects of medication use and comorbid depression were assessed. RESULTS Sleep and PTSD symptoms improved in parallel. The relation was moderated by depression: Sleep problems at the start of therapy did not predict improvement in PTSD symptoms during treatment for patients without comorbid depression. Patients with comorbid depression, however, showed less rapid decreases in PTSD symptoms, but comparable overall outcome, if their sleep quality was poor. Residual sleep problems at the end of treatment did not predict PTSD symptoms at follow-up once residual PTSD symptoms were taken into account. CONCLUSIONS CT-PTSD leads to simultaneous improvement in sleep and PTSD symptoms. Sleep problems may reduce the speed of recovery in PTSD patients with comorbid depression. For these patients, additional treatment sessions are indicated to achieve comparable outcomes, and additional interventions targeting sleep may be beneficial. For those without comorbid depression, self-reported sleep problems did not interfere with response to trauma-focused psychological treatment.
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Affiliation(s)
- Miriam J J Lommen
- Department of Experimental Psychology, University of Oxford, Oxford, UK.,Oxford NIHR Cognitive Health Clinical Research Facility, Oxford, UK
| | - Nick Grey
- National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
| | - David M Clark
- Department of Experimental Psychology, University of Oxford, Oxford, UK.,Oxford NIHR Cognitive Health Clinical Research Facility, Oxford, UK.,National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
| | - Jennifer Wild
- Department of Experimental Psychology, University of Oxford, Oxford, UK.,Oxford NIHR Cognitive Health Clinical Research Facility, Oxford, UK
| | - Richard Stott
- National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
| | - Anke Ehlers
- Department of Experimental Psychology, University of Oxford, Oxford, UK.,Oxford NIHR Cognitive Health Clinical Research Facility, Oxford, UK.,National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
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71
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Reliability of Therapist Effects in Practice-Based Psychotherapy Research: A Guide for the Planning of Future Studies. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2016; 44:598-613. [DOI: 10.1007/s10488-016-0736-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Schnurr PP, Lunney CA. SYMPTOM BENCHMARKS OF IMPROVED QUALITY OF LIFE IN PTSD. Depress Anxiety 2016; 33:247-55. [PMID: 26882293 DOI: 10.1002/da.22477] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 01/19/2016] [Accepted: 01/24/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Although research has shown that PTSD symptom change relates to improved quality of life, the question of how much improvement in PTSD symptoms is necessary to result in meaningful improvements in quality of life remains unanswered. We used data from a randomized clinical trial of psychotherapy for PTSD in female military veterans and active duty personnel to examine the correspondence between benchmarks of improvement in PTSD symptoms and changes in quality of life. METHODS Participants were 235 female veterans and Army soldiers who were randomized to 10 weekly sessions of Prolonged Exposure or Present-Centered Therapy. We operationalized PTSD symptom change in terms of four progressively stringent mutually exclusive definitions-No Response, Response, Loss of Diagnosis, and Remission-successively comparing each category to the prior one: No Response versus Response, Response versus Loss of Diagnosis, and Loss of Diagnosis versus Remission. Outcomes were clinically meaningful improvements and good endpoints in domains of clinician-rated and self-reported quality of life. RESULTS Response was associated with improvement on almost all measures, but with only one good endpoint. Loss of Diagnosis was associated with improvement on all measures except self-rated social functioning and with achieving a good endpoint on all measures. Remission was associated with improvement in clinician-rated social impairment and a good endpoint in clinician-rated occupational impairment. CONCLUSIONS For most domains of quality of life, treating a patient until the patient no longer meets diagnostic criteria would be optimal. For some domains, further improvements may result by helping a patient achieve remission.
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Affiliation(s)
- Paula P Schnurr
- Executive Division, National Center for PTSD, White River Junction, Vermont.,Department of Psychiatry, Dartmouth Medical School, Hanover, New Hampshire
| | - Carole A Lunney
- Executive Division, National Center for PTSD, White River Junction, Vermont
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Emotional Intensity of Trauma Memory as Moderator of the Relationship Between Posttraumatic Cognitions and PTSD Symptoms. JOURNAL OF PACIFIC RIM PSYCHOLOGY 2016. [DOI: 10.1017/prp.2016.4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Individuals develop three types of cognitions in the aftermath of a traumatic experience: negative cognitions about the self, negative cognitions about the world, and self-blame (Foa et al., 1999 ). Although the relationship of posttraumatic stress disorder (PTSD) symptoms and posttraumatic cognitions has been supported in literature, memory-related responses affecting this relationship need further exploration. It was the intention of the present study to address this gap by examining the moderating role of emotional intensity of trauma memory in the relationship between posttraumatic cognitions and PTSD symptoms. In a sample of survivors of typhoon Haiyan ( N = 632), one of the strongest typhoons ever recorded, it was found that in general, negative cognitions about the self and the world, but not self-blame, predict PTSD symptoms; and emotional intensity of trauma memory generally moderates the relationship between posttraumatic cognitions and PTSD. The findings of the study would be useful in the development and enhancement of interventions to help the survivors of natural disasters in maintaining their mental health and wellbeing.
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Abstract
AbstractReturning to the scene of the trauma is often recommended as part of trauma-focused cognitive-behavioural therapies for post-traumatic stress disorder (PTSD). Many clinicians avoid site visits due to lack of confidence or practical constraints; however, recent research suggests this is a valuable part of treatment. This article summarizes a rationale for including the site visit as part of cognitive therapy for PTSD, as well as the main considerations about when to carry it out in treatment. A practical framework for planning and implementing site visits is described.
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Schubert CF, Schmidt U, Rosner R. Posttraumatic Growth in Populations with Posttraumatic Stress Disorder-A Systematic Review on Growth-Related Psychological Constructs and Biological Variables. Clin Psychol Psychother 2015; 23:469-486. [DOI: 10.1002/cpp.1985] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 09/09/2015] [Accepted: 09/09/2015] [Indexed: 01/23/2023]
Affiliation(s)
- Christine F. Schubert
- RG Molecular Psychotraumatology; Max Planck Institute of Psychiatry; Munich Germany
- Department of Clinical and Biological Psychology; Catholic University of Eichstaett-Ingolstadt; Eichstaett Germany
| | - Ulrike Schmidt
- RG Molecular Psychotraumatology; Max Planck Institute of Psychiatry; Munich Germany
| | - Rita Rosner
- Department of Clinical and Biological Psychology; Catholic University of Eichstaett-Ingolstadt; Eichstaett Germany
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Peters E, Crombie T, Agbedjro D, Johns LC, Stahl D, Greenwood K, Keen N, Onwumere J, Hunter E, Smith L, Kuipers E. The long-term effectiveness of cognitive behavior therapy for psychosis within a routine psychological therapies service. Front Psychol 2015; 6:1658. [PMID: 26579041 PMCID: PMC4625031 DOI: 10.3389/fpsyg.2015.01658] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 10/14/2015] [Indexed: 11/18/2022] Open
Abstract
Randomised controlled trials (RCTs) have shown the efficacy of CBTp, however, few studies have considered its long-term effectiveness in routine services. This study reports the outcomes of clients seen in a psychological therapies clinic, set up following positive results obtained from an RCT (Peters et al., 2010). The aims were to evaluate the effectiveness of CBTp, using data from the service’s routine assessments for consecutive referrals over a 12 years period, and assess whether gains were maintained at a 6+ months’ follow-up. Of the 476 consenting referrals, all clients (N = 358) who received ≥5 therapy sessions were offered an assessment at four time points (baseline, pre-, mid-, and end of therapy) on measures assessing current psychosis symptoms, emotional problems, general well-being and life satisfaction. A sub-set (N = 113) was assessed at a median of 12 months after finishing therapy. Following the waiting list (median of 3 months) clients received individualized, formulation-based CBTp for a median number of 19 sessions from 121 therapists with a range of experience receiving regular supervision. Clients showed no meaningful change on any measure while on the waiting list (Cohen’s d <= 0.23). In contrast, highly significant improvements following therapy, all of which were significantly greater than changes during the waiting list, were found on all domains assessed (Cohen’s d: 0.44–0.75). All gains were maintained at follow-up (Cohen’s d: 0.29–0.82), with little change between end of therapy and follow-up (Cohen’s d <= 0.18). Drop-out rate from therapy was low (13%). These results demonstrate the positive and potentially enduring impact of psychological therapy on a range of meaningful outcomes for clients with psychosis. The follow-up assessments were conducted on only a sub-set, which may not generalize to the full sample. Nevertheless this study is the largest of its kind in psychosis, and has important implications for the practice of CBTp in clinical services.
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Affiliation(s)
- Emmanuelle Peters
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London London, UK ; Psychological Interventions Clinic for Outpatients with Psychosis, South London and Maudsley NHS Trust London, UK ; NIHR Biomedical Research Centre for Mental Health, South London and Maudsley NHS Trust, King's College London London, UK
| | - Tessa Crombie
- Psychological Interventions Clinic for Outpatients with Psychosis, South London and Maudsley NHS Trust London, UK
| | - Deborah Agbedjro
- Department of Biostatistics, Institute of Psychiatry, Psychology and Neuroscience, King's College London London, UK
| | - Louise C Johns
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London London, UK ; Psychological Interventions Clinic for Outpatients with Psychosis, South London and Maudsley NHS Trust London, UK
| | - Daniel Stahl
- Department of Biostatistics, Institute of Psychiatry, Psychology and Neuroscience, King's College London London, UK
| | - Kathryn Greenwood
- Department of Psychology, Sussex University Sussex, UK ; Sussex Partnership NHS Foundation Trust Sussex, UK
| | - Nadine Keen
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London London, UK ; Psychological Interventions Clinic for Outpatients with Psychosis, South London and Maudsley NHS Trust London, UK
| | - Juliana Onwumere
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London London, UK ; Psychological Interventions Clinic for Outpatients with Psychosis, South London and Maudsley NHS Trust London, UK
| | - Elaine Hunter
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London London, UK ; Psychological Interventions Clinic for Outpatients with Psychosis, South London and Maudsley NHS Trust London, UK
| | - Laura Smith
- Psychological Interventions Clinic for Outpatients with Psychosis, South London and Maudsley NHS Trust London, UK
| | - Elizabeth Kuipers
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London London, UK ; Psychological Interventions Clinic for Outpatients with Psychosis, South London and Maudsley NHS Trust London, UK ; NIHR Biomedical Research Centre for Mental Health, South London and Maudsley NHS Trust, King's College London London, UK
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77
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Brady F, Warnock-Parkes E, Barker C, Ehlers A. Early in-session predictors of response to trauma-focused cognitive therapy for posttraumatic stress disorder. Behav Res Ther 2015; 75:40-7. [PMID: 26523887 PMCID: PMC4686047 DOI: 10.1016/j.brat.2015.10.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 09/26/2015] [Accepted: 10/01/2015] [Indexed: 11/16/2022]
Abstract
Trauma-focused cognitive behaviour therapy is effective in treating posttraumatic stress disorder but non-response rates range between 25% and 50%. Results of previous research on patient characteristics predicting outcome are inconsistent and mainly focused on demographic and diagnostic variables. This study examined whether behavioural predictors of poor treatment response can be observed in early sessions. It was predicted that greater patient perseveration, lower expression of thoughts and feelings and weaker therapeutic alliance would be associated with poorer outcomes. We also explored the relationships of patient behaviours with therapeutic alliance and the efficiency and competence of treatment delivery. Audio or video recordings of the initial treatment sessions of 58 patients who had shown either good (n = 34) or poor response (n = 24) to cognitive therapy for PTSD (CT-PTSD, Ehlers & Clark, 2000) were blindly coded for patient perseveration, expression of thoughts and feelings, therapeutic alliance, efficiency and competency of treatment delivery and therapist competence. Poor responders showed more perseveration and less expression of thoughts and feelings in the initial session. Patient perseveration and low expression of thoughts and feelings were associated with poorer therapeutic alliance and compromised treatment delivery. Patients with these behavioural characteristics may benefit from additional treatment strategies. Limitations of the study and implications for clinical practice are discussed. The study examined whether patient behaviour in initial treatment sessions predicts outcome. Poor treatment responders showed more perseveration and lower expression of thoughts and feelings than good responders. These patient characteristics were associated with poorer therapeutic alliance. These characteristics were also associated with lower ratings of the efficacy and competency of treatment delivery.
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Affiliation(s)
- Francesca Brady
- Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London, WC1E 6BT, UK
| | - Emma Warnock-Parkes
- University of Oxford, Department of Experimental Psychology, South Parks Road, Oxford, OX1 3UD, UK; NIHR Oxford Cognitive Health Clinical Research Facility, UK; King's College London, Department of Psychology, Institute of Psychiatry, De Crespigny Park, London, SE5 8AF, UK; NIHR Biomedical Research Centre for Mental Health, South London and Maudsley NHS Trust and King's College London, UK.
| | - Chris Barker
- Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London, WC1E 6BT, UK
| | - Anke Ehlers
- University of Oxford, Department of Experimental Psychology, South Parks Road, Oxford, OX1 3UD, UK; NIHR Oxford Cognitive Health Clinical Research Facility, UK
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Stirman SW, Matza A, Gamarra J, Toder K, Xhezo R, Evans AC, Hurford M, Beck AT, Crits-Christoph P, Creed T. System-Level Influences on the Sustainability of a Cognitive Therapy Program in a Community Behavioral Health Network. Psychiatr Serv 2015; 66:734-42. [PMID: 25828878 PMCID: PMC4490058 DOI: 10.1176/appi.ps.201400147] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to examine influences on the sustainability of a program to implement an evidence-based psychotherapy in a mental health system. METHODS Interviews with program administrators, training consultants, agency administrators, and supervisors (N=24), along with summaries of program evaluation data and program documentation, were analyzed with a directed content-analytic approach. RESULTS Findings suggested a number of interconnected and interacting influences on sustainability, including alignment with emerging sociopolitical influences and system and organizational priorities; program-level adaptation and evolution; intervention flexibility; strong communication, collaboration, planning, and support; and perceived benefit. These individual factors appeared to mutually influence one another and contribute to the degree of program sustainability achieved at the system level. Although most influences were positive, financial planning and support emerged as potentially both facilitator and barrier, and evaluation of benefits at the patient level remained a challenge. CONCLUSIONS Several factors appeared to contribute to the sustainability of a psychosocial intervention in a large urban mental health system and warrant further investigation. Understanding interconnections between multiple individual facilitators and barriers appears critical to advancing understanding of sustainability in dynamic systems and adds to emerging recommendations for other implementation efforts. In particular, implications of the findings include the importance of implementation strategies, such as long-term planning, coalition building, clarifying roles and expectations, planned adaptation, evaluation, diversification of financing strategies, and incentivizing implementation.
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Affiliation(s)
- Shannon Wiltsey Stirman
- Dr. Stirman and Ms. Gamarra are with the Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) National Center for PTSD, Boston (e-mail: ). Dr. Stirman is also with the Department of Psychiatry, Boston University. Dr. Matza is with the Lesbian, Gay, Bisexual, and Transgender Program, Office of Patient Care Services, U.S. Department of Veterans Affairs Central Office, Washington, D.C. Ms. Toder, Dr. Beck, Dr. Crits-Christoph, and Dr. Creed are with the Department of Psychiatry, University of Pennsylvania, Philadelphia. Ms. Xhezo, Dr. Evans, and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia
| | - Alexis Matza
- Dr. Stirman and Ms. Gamarra are with the Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) National Center for PTSD, Boston (e-mail: ). Dr. Stirman is also with the Department of Psychiatry, Boston University. Dr. Matza is with the Lesbian, Gay, Bisexual, and Transgender Program, Office of Patient Care Services, U.S. Department of Veterans Affairs Central Office, Washington, D.C. Ms. Toder, Dr. Beck, Dr. Crits-Christoph, and Dr. Creed are with the Department of Psychiatry, University of Pennsylvania, Philadelphia. Ms. Xhezo, Dr. Evans, and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia
| | - Jennifer Gamarra
- Dr. Stirman and Ms. Gamarra are with the Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) National Center for PTSD, Boston (e-mail: ). Dr. Stirman is also with the Department of Psychiatry, Boston University. Dr. Matza is with the Lesbian, Gay, Bisexual, and Transgender Program, Office of Patient Care Services, U.S. Department of Veterans Affairs Central Office, Washington, D.C. Ms. Toder, Dr. Beck, Dr. Crits-Christoph, and Dr. Creed are with the Department of Psychiatry, University of Pennsylvania, Philadelphia. Ms. Xhezo, Dr. Evans, and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia
| | - Katherine Toder
- Dr. Stirman and Ms. Gamarra are with the Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) National Center for PTSD, Boston (e-mail: ). Dr. Stirman is also with the Department of Psychiatry, Boston University. Dr. Matza is with the Lesbian, Gay, Bisexual, and Transgender Program, Office of Patient Care Services, U.S. Department of Veterans Affairs Central Office, Washington, D.C. Ms. Toder, Dr. Beck, Dr. Crits-Christoph, and Dr. Creed are with the Department of Psychiatry, University of Pennsylvania, Philadelphia. Ms. Xhezo, Dr. Evans, and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia
| | - Regina Xhezo
- Dr. Stirman and Ms. Gamarra are with the Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) National Center for PTSD, Boston (e-mail: ). Dr. Stirman is also with the Department of Psychiatry, Boston University. Dr. Matza is with the Lesbian, Gay, Bisexual, and Transgender Program, Office of Patient Care Services, U.S. Department of Veterans Affairs Central Office, Washington, D.C. Ms. Toder, Dr. Beck, Dr. Crits-Christoph, and Dr. Creed are with the Department of Psychiatry, University of Pennsylvania, Philadelphia. Ms. Xhezo, Dr. Evans, and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia
| | - Arthur C Evans
- Dr. Stirman and Ms. Gamarra are with the Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) National Center for PTSD, Boston (e-mail: ). Dr. Stirman is also with the Department of Psychiatry, Boston University. Dr. Matza is with the Lesbian, Gay, Bisexual, and Transgender Program, Office of Patient Care Services, U.S. Department of Veterans Affairs Central Office, Washington, D.C. Ms. Toder, Dr. Beck, Dr. Crits-Christoph, and Dr. Creed are with the Department of Psychiatry, University of Pennsylvania, Philadelphia. Ms. Xhezo, Dr. Evans, and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia
| | - Matthew Hurford
- Dr. Stirman and Ms. Gamarra are with the Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) National Center for PTSD, Boston (e-mail: ). Dr. Stirman is also with the Department of Psychiatry, Boston University. Dr. Matza is with the Lesbian, Gay, Bisexual, and Transgender Program, Office of Patient Care Services, U.S. Department of Veterans Affairs Central Office, Washington, D.C. Ms. Toder, Dr. Beck, Dr. Crits-Christoph, and Dr. Creed are with the Department of Psychiatry, University of Pennsylvania, Philadelphia. Ms. Xhezo, Dr. Evans, and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia
| | - Aaron T Beck
- Dr. Stirman and Ms. Gamarra are with the Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) National Center for PTSD, Boston (e-mail: ). Dr. Stirman is also with the Department of Psychiatry, Boston University. Dr. Matza is with the Lesbian, Gay, Bisexual, and Transgender Program, Office of Patient Care Services, U.S. Department of Veterans Affairs Central Office, Washington, D.C. Ms. Toder, Dr. Beck, Dr. Crits-Christoph, and Dr. Creed are with the Department of Psychiatry, University of Pennsylvania, Philadelphia. Ms. Xhezo, Dr. Evans, and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia
| | - Paul Crits-Christoph
- Dr. Stirman and Ms. Gamarra are with the Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) National Center for PTSD, Boston (e-mail: ). Dr. Stirman is also with the Department of Psychiatry, Boston University. Dr. Matza is with the Lesbian, Gay, Bisexual, and Transgender Program, Office of Patient Care Services, U.S. Department of Veterans Affairs Central Office, Washington, D.C. Ms. Toder, Dr. Beck, Dr. Crits-Christoph, and Dr. Creed are with the Department of Psychiatry, University of Pennsylvania, Philadelphia. Ms. Xhezo, Dr. Evans, and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia
| | - Torrey Creed
- Dr. Stirman and Ms. Gamarra are with the Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) National Center for PTSD, Boston (e-mail: ). Dr. Stirman is also with the Department of Psychiatry, Boston University. Dr. Matza is with the Lesbian, Gay, Bisexual, and Transgender Program, Office of Patient Care Services, U.S. Department of Veterans Affairs Central Office, Washington, D.C. Ms. Toder, Dr. Beck, Dr. Crits-Christoph, and Dr. Creed are with the Department of Psychiatry, University of Pennsylvania, Philadelphia. Ms. Xhezo, Dr. Evans, and Dr. Hurford are with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia
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Corrigan FM, Hull AM. Neglect of the complex: why psychotherapy for post-traumatic clinical presentations is often ineffective. BJPsych Bull 2015; 39:86-9. [PMID: 26191439 PMCID: PMC4478904 DOI: 10.1192/pb.bp.114.046995] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 02/22/2014] [Accepted: 03/11/2014] [Indexed: 11/23/2022] Open
Abstract
Evidence of efficacy in studies of post-traumatic conditions is largely derived from studies in which variables are kept to a minimum. Extrapolation of treatments from uncomplicated disorders to complex conditions may therefore be called evidence-based without being evidenced. Complex conditions with polysymptomatic presentations and extensive comorbidity are being denied proper evaluation, and patients most severely traumatised from the early stages of their development are not provided with rigorously evaluated psychotherapies because they are more difficult to study in the manner approved by research protocols. Such evidence as there is suggests that the simple extension of treatments for uncomplicated disorders is seriously inadequate. This has significant implications for health services responsible for the provision of the most efficacious treatments to those whose disorders arise from severe trauma, often very early in their life.
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Knowing our ‘ABCs’: self-reflection using cognitive-behavioural formulation of client–therapist interaction in work with a survivor of torture. COGNITIVE BEHAVIOUR THERAPIST 2015. [DOI: 10.1017/s1754470x15000203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractSelf-reflection can aid therapist development, particularly interpersonal skills. It can be achieved through using cognitive-behavioural therapy techniques, for example, formulations of the therapist's cognitions and behaviours have been used to aid self-reflection. As interpersonal skills may be an area that benefits from self-reflection, an approach to formulating the interaction between client and therapist may be beneficial. This study reports the use of simple ‘antecedent-belief-consequence’ (ABC) formulations for the client and therapist to conceptualize their interaction. This description of a treatment failure focuses on cross-cultural work with a survivor of torture, where self-reflection may be particularly indicated to promote cultural competence and address the impact of the content on the therapist. ABC formulations for the client and therapist were completed and through this structured self-reflection, the therapist was able to identify the impact of her own beliefs on the process of therapy. This method identified areas for further development and generated hypotheses for how to continue therapy with this client. Using ABC formulations then may provide a useful and structured way to conduct self-reflection with explicit focus on the interaction between client and therapist.
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Pull CN, Pull CB. Current Status of Treatment for Posttraumatic Stress Disorder: Focus on Treatments Combining Pharmacotherapy and Cognitive-Behavioral Therapy. Int J Cogn Ther 2014. [DOI: 10.1521/ijct.2014.7.2.149] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kleim B, Grey N, Wild J, Nussbeck FW, Stott R, Hackmann A, Clark DM, Ehlers A. Cognitive change predicts symptom reduction with cognitive therapy for posttraumatic stress disorder. J Consult Clin Psychol 2013; 81:383-93. [PMID: 23276122 PMCID: PMC3665307 DOI: 10.1037/a0031290] [Citation(s) in RCA: 124] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Revised: 10/10/2012] [Accepted: 11/13/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVE There is a growing body of evidence for the effectiveness of trauma-focused cognitive behavior therapy (TF-CBT) for posttraumatic stress disorder (PTSD), but few studies to date have investigated the mechanisms by which TF-CBT leads to therapeutic change. Models of PTSD suggest that a core treatment mechanism is the change in dysfunctional appraisals of the trauma and its aftermath. If this is the case, then changes in appraisals should predict a change in symptoms. The present study investigated whether cognitive change precedes symptom change in Cognitive Therapy for PTSD, a version of TF-CBT. METHOD The study analyzed weekly cognitive and symptom measures from 268 PTSD patients who received a course of Cognitive Therapy for PTSD, using bivariate latent growth modeling. RESULTS Results showed that (a) dysfunctional trauma-related appraisals and PTSD symptoms both decreased significantly over the course of treatment, (b) changes in appraisals and symptoms were correlated, and (c) weekly change in appraisals significantly predicted subsequent reduction in symptom scores (both corrected for the general decrease over the course of therapy). Changes in PTSD symptom severity did not predict subsequent changes in appraisals. CONCLUSIONS The study provided preliminary evidence for the temporal precedence of a reduction in negative trauma-related appraisals in symptom reduction during trauma-focused CBT for PTSD. This supports the role of change in appraisals as an active therapeutic mechanism.
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Affiliation(s)
- Birgit Kleim
- Department of Psychology, King’s College London, London, England, and Department of Psychology, University of Zurich, Zurich, Switzerland
| | - Nick Grey
- NIHR Biomedical Research Centre for Mental Health, South London and Maudsley NHS Trust and King’s College London
| | - Jennifer Wild
- David M. Clark, and Anke Ehlers, Department of Experimental Psychology, University of Oxford, Oxford, and Department of Psychology, Institute of Psychiatry, King’s College London
| | | | | | - Ann Hackmann
- Department of Psychiatry, University of Oxford and Department of Psychology, Institute of Psychiatry, King’s College London
| | - David M. Clark
- David M. Clark, and Anke Ehlers, Department of Experimental Psychology, University of Oxford, Oxford, and Department of Psychology, Institute of Psychiatry, King’s College London
| | - Anke Ehlers
- David M. Clark, and Anke Ehlers, Department of Experimental Psychology, University of Oxford, Oxford, and Department of Psychology, Institute of Psychiatry, King’s College London
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