The relative efficacy of bona fide psychotherapies for treating post-traumatic stress disorder: a meta-analysis of direct comparisons

Randomized clinical trial comparing affect regulation and supportive group therapies for victimization-related PTSD with incarcerated women

Traumatic victimization and associated problems with posttraumatic stress disorder (PTSD) and affect dysregulation are prevalent among incarcerated women, but there is limited evidence to support psychotherapeutic interventions for these problems in this underserved population. A group psychotherapy designed to enhance affect regulation without trauma memory processing-Trauma Affect Regulation: Guide for Education and Therapy (TARGET)-was compared to a supportive group therapy (SGT) in a randomized clinical trial with 72 incarcerated women with full or partial PTSD. Both interventions achieved statistically significant reductions in PTSD and associated symptom severity and increased self-efficacy. Dropout rates for both interventions were low (<5%). TARGET was more effective than SGT in increasing sense of forgiveness toward others who have caused harm in the past. Group therapy that teaches affect regulation may enhance incarcerated women's ability to achieve affective resolution (forgiveness) while also reducing their victimization-related PTSD and associated symptoms. Experiential-focused supportive group therapy also may reduce victimization-related PTSD and associated symptoms. Both group therapy approaches warrant further study with this vulnerable population.

Sub-Clinical Trauma in the Treatment of Partner Violent Offenders with Substance Dependence

PURPOSE

With an established association between PTSD and the perpetration of intimate partner violence, evaluating the effectiveness of emerging integrated treatments for dual substance use and partner violent behavior on individuals with a significant trauma history may serve to improve treatment outcomes for clients with axis I psychopathology. This paper examined the association between sub-clinical trauma, treatment compliance, and recidivism in a sample of male, substance dependent intimate partner violence offenders.

DESIGN/METHODOLOGY/APPROACH

The described investigation utilized violence perpetration, substance use, and trauma data collected during a larger, randomized control treatment evaluation study. Data was collected from 56 participants at 4 time points throughout treatment.

FINDINGS

Participants with a significant trauma history comprised 33.9% of the sample and demonstrated poorer treatment attendance, as well as heightened partner violence recidivism throughout treatment, as compared to participants who denied experiencing a significant trauma. This finding held across participants receiving substance treatment only and combined treatment addressing substance use and violence.

PRACTICAL IMPLICATIONS

IPV perpetrators often have a trauma history themselves. The association between sub-clinical trauma symptomatology and poor treatment outcomes calls for the adaptation of current partner violence intervention models to accommodate the large subset of clients who suffer from either sub-clinical or clinically significant trauma.

ORIGINALITY/VALUE

This paper is the first to address the potential influence of sub-clinical trauma on the integrated treatment of substance use and partner violence within a forensic sample. Suggestions are offered to adapt existing treatment models to accommodate dual diagnosed clients.

Meta-analysis of dropout in treatments for posttraumatic stress disorder

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.

Trajectories of response to treatment for posttraumatic stress disorder

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.

Behavioral activation and therapeutic exposure: an investigation of relative symptom changes in PTSD and depression during the course of integrated behavioral activation, situational exposure, and imaginal exposure techniques

Effectiveness of exposure therapy for posttraumatic stress disorder (PTSD) may be adversely influenced by comorbid disorders. The present study investigated behavioral activation and therapeutic exposure (BA-TE), a new integrated treatment designed specifically for comorbid symptoms of PTSD and depression. Combat veterans with PTSD (N = 117) completed eight sessions of BA-TE that included two phases of treatment: (a) behavioral activation (BA) in which some activities involved situational exposures and (b) BA and situational exposures with imaginal exposures. Findings supported improvements in symptoms of PTSD, and overlapping symptoms of PTSD and depression, but not in nonoverlapping symptoms of depression. The findings also demonstrated a relatively consistent rate of change in PTSD and depression symptoms during BA-TE, despite the addition of imaginal exposures midway through the treatment. Together, these findings provide preliminary support for BA-TE as a treatment for PTSD and depression, and highlight the utility of transdiagnostic treatments in addressing comorbidity and symptom overlap.

Treating posttraumatic stress disorder in first responders: a systematic review

First responders are generally considered to be at greater risk for full or partial posttraumatic stress disorder (PTSD) than most other occupations because their duties routinely entail confrontation with traumatic stressors. These critical incidents typically involve exposure to life threat, either directly or as a witness. There is a substantial literature that has examined the risk factors, symptom presentation, course, and comorbidities of PTSD in this population. However, to our knowledge, there are no systematic reviews of treatment studies for first responders. We conducted a systematic review of the PTSD treatment literature (English and non-English) in order to evaluate such treatment proposals based on what is known about treating PTSD in first responders. We especially sought to identify randomized controlled trials (RCTs) whose primary outcome was PTSD. Our search identified 845 peer-reviewed articles of which 0.002% (n=2) were bona fide RCTs of PTSD treatment in first responders. Both studies tested a psychosocial treatment. We did not locate a single psychopharmacologic RCT for PTSD in first responders. An additional 2 psychosocial studies and 13 case or observational studies comprised the remaining extant literature. Though both RCTs showed significant large treatment effects (d=1.37; h=0.92), the literature is startlingly sparse and is not sufficient for evidence-based recommendations for first responders.

Emergence of delayed posttraumatic stress disorder symptoms related to sexual trauma: patient-centered and trauma-cognizant management by physical therapists

BACKGROUND AND PURPOSE

Sexual violence has been identified as one of the most common predictors of posttraumatic stress disorder (PTSD). This case report describes the emergence of delayed PTSD symptoms, disclosure of history of sexual trauma, and the influence of re-experiencing, avoidance, and hyperarousal symptoms on physical therapy treatment.

CASE DESCRIPTION

A 60-year-old woman was seen for treatment of low back pain.

DISCUSSION

of a discord between fear of falling and no balance impairments led to disclosure of sexual assault by a physician at 19 years of age. The patient's PTSD symptoms emerged after 10 weeks of physical therapy. The physical therapists monitored somatic responses and body language closely and modified and planned treatment techniques to avoid PTSD triggers and limit hyperarousal. Collaborative communication approaches included reinforcement of cognitive-behavioral strategies introduced by her psychotherapists.

OUTCOMES

Trauma-cognizant approaches supported the patient's efforts to manage PTSD symptoms sufficiently to tolerate physical therapy and participate in a back care class. Nonlinear psychological healing is illustrated.

DISCUSSION

Symptoms of PTSD may emerge during physical therapy treatment, and patient-sensitive responses to disclosure are important. The trauma-cognizant approach (2-way communication, patient-centered management, and integration of psychological elements into clinical decision making) helped identify and respond to triggers. The physical therapists reinforced cognitive-behavioral strategies introduced by psychotherapists to manage PTSD symptoms. Patient-centered care with further refinement to a trauma-cognizant approach may play an important role in assisting patients with PTSD or a history of sexual trauma to manage symptoms while addressing rehabilitation needs.

A randomized clinical trial comparing affect regulation and social problem-solving psychotherapies for mothers with victimization-related PTSD

Addressing affect dysregulation may provide a complementary alternative or adjunctive approach to the empirically supported trauma memory processing models of cognitive behavior therapy (CBT) for posttraumatic stress disorder (PTSD). A CBT designed to enhance affect regulation without trauma memory processing--trauma affect regulation: guide for education and therapy (TARGET)--was compared to present centered therapy (PCT) and wait-list (WL) conditions in a randomized clinical trial with 146 primarily low-income and ethnoracial minority mothers with PTSD. TARGET achieved statistically and clinically significant improvement on PTSD and affect regulation measures compared to WL, with more consistent and sustained (over a 6-month follow-up period) evidence of improvement than PCT. Drop-out rates (~25%) were comparable in TARGET and PCT, similar to those previously reported for trauma memory processing CBTs. Symptom worsening was rare (2-8%) and transient. Affect regulation-based CBT without trauma memory processing warrants further research as a potentially efficacious therapy for victimization-related PTSD.

Interventions to improve work outcomes in work-related PTSD: a systematic review

BACKGROUND

Posttraumatic stress disorder acquired at work can be debilitating both for workers and their employers. The disorder can result in increased sick leave, reduced productivity, and even unemployment. Furthermore, workers are especially unlikely to return to their previous place of employment after a traumatic incident at work because of the traumatic memories and symptoms of avoidance that typically accompany the disorder. Therefore, intervening in work-related PTSD becomes especially important in order to get workers back to the workplace.

METHODS

A systematic literature search was conducted using Medline, PsycINFO, Embase, and Web of Science. The articles were independently screened based on inclusion and exclusion criteria, followed by a quality assessment of all included articles.

RESULTS

The systematic search identified seven articles for inclusion in the review. These consisted of six research articles and one systematic review. The review focused specifically on interventions using real exposure techniques for anxiety disorders in the workplace. In the research articles addressed in the current review, study populations included police officers, public transportation workers, and employees injured at work. The studies examined the effectiveness of EMDR, cognitive-behavioural techniques, and an integrative therapy approach called brief eclectic psychotherapy. Interestingly, 2 of the 6 research articles addressed add-on treatments for workplace PTSD, which were designed to treat workers with PTSD who failed to respond to traditional evidence-based psychotherapy.

CONCLUSIONS

Results of the current review suggest that work-related interventions show promise as effective strategies for promoting return to work in employees who acquired PTSD in the workplace. Further research is needed in this area to determine how different occupational groups with specific types of traumatic exposure might respond differently to work-tailored treatments.

Group cognitive behaviour therapy for military service-related post-traumatic stress disorder: effectiveness, sustainability and repeatability

OBJECTIVE

The aim of this study was to assess 12 month outcomes of Australian combat veterans with post-traumatic stress disorder (PTSD) who participated in a 6 week group-based CBT programme at the Toowong Private Hospital. The study population included 496 consecutive admissions to the programme between 1999 and 2008.

METHOD

Self-report measures of PTSD, depression, anxiety, anger, alcohol use, relationship satisfaction and quality of life parameters were collected at intake and 3, 6 and 12 months post intake.

RESULTS

Statistically significant and sustained improvements were noted in 12 month outcome measures for PTSD, depression, anxiety, alcohol use, anger, and quality of life. PTSD symptom reduction occurred consistently each year for 9 years and exhibited an aggregated effect size of 0.68.

CONCLUSIONS

This naturalistic research demonstrates that treatment administered under clinical conditions produces equivocal magnitudes of positive change in terms of PTSD symptoms when compared with existing efficacy data in individual and group treatments. Further, these symptomatic gains are sustainable and consistently reproducible. The benefits noted from group therapy were seen as independent of whether or not individual treatment was in place.

A controlled comparison of the effectiveness and efficiency of two psychological therapies for posttraumatic stress disorder: eye movement desensitization and reprocessing vs. emotional freedom techniques

The present study reports on the first ever controlled comparison between eye movement desensitization and reprocessing (EMDR) and emotional freedom techniques (EFT) for posttraumatic stress disorder. A total of 46 participants were randomized to either EMDR (n = 23) or EFT (n = 23). The participants were assessed at baseline and then reassessed after an 8-week waiting period. Two further blind assessments were conducted at posttreatment and 3-months follow-up. Overall, the results indicated that both interventions produced significant therapeutic gains at posttreatment and follow-up in an equal number of sessions. Similar treatment effect sizes were observed in both treatment groups. Regarding clinical significant changes, a slightly higher proportion of patients in the EMDR group produced substantial clinical changes compared with the EFT group. Given the speculative nature of the theoretical basis of EFT, a dismantling study on the active ingredients of EFT should be subject to future research.

The safety and efficacy of {+/-}3,4-methylenedioxymethamphetamine-assisted psychotherapy in subjects with chronic, treatment-resistant posttraumatic stress disorder: the first randomized controlled pilot study

Case reports indicate that psychiatrists administered ±3,4-methylenedioxymethamphetamine (MDMA) as a catalyst to psychotherapy before recreational use of MDMA as 'Ecstasy' resulted in its criminalization in 1985. Over two decades later, this study is the first completed clinical trial evaluating MDMA as a therapeutic adjunct. Twenty patients with chronic posttraumatic stress disorder, refractory to both psychotherapy and psychopharmacology, were randomly assigned to psychotherapy with concomitant active drug (n = 12) or inactive placebo (n = 8) administered during two 8-h experimental psychotherapy sessions. Both groups received preparatory and follow-up non-drug psychotherapy. The primary outcome measure was the Clinician-Administered PTSD Scale, administered at baseline, 4 days after each experimental session, and 2 months after the second session. Neurocognitive testing, blood pressure, and temperature monitoring were performed. After 2-month follow-up, placebo subjects were offered the option to re-enroll in the experimental procedure with open-label MDMA. Decrease in Clinician-Administered PTSD Scale scores from baseline was significantly greater for the group that received MDMA than for the placebo group at all three time points after baseline. The rate of clinical response was 10/12 (83%) in the active treatment group versus 2/8 (25%) in the placebo group. There were no drug-related serious adverse events, adverse neurocognitive effects or clinically significant blood pressure increases. MDMA-assisted psychotherapy can be administered to posttraumatic stress disorder patients without evidence of harm, and it may be useful in patients refractory to other treatments.

Efficacy of cognitive behavioral therapy for anxiety disorders: a review of meta-analytic findings

Numerous clinical trials have supported the efficacy of cognitive behavioral therapy (CBT) for the treatment of anxiety disorders. Accordingly, CBT has been formally recognized as an empirically supported treatment for anxiety-related conditions. This article reviews the evidence supporting the efficacy of CBT for anxiety disorders. Specifically, contemporary meta-analytic studies on the treatment of anxiety disorders are reviewed and the efficacy of CBT is examined. Although the specific components of CBT differ depending on the study design and the anxiety disorder treated, meta-analyses suggest that CBT procedures (particularly exposure-based approaches) are highly efficacious. CBT generally outperforms wait-list and placebo controls. Thus, CBT provides incremental efficacy above and beyond nonspecific factors. For some anxiety disorders, CBT also tends to outperform other psychosocial treatment modalities. The implications of available meta-analytic findings in further delineating the efficacy and dissemination of CBT for anxiety disorders are discussed.

Do all psychological treatments really work the same in posttraumatic stress disorder?

A recent meta-analysis by Benish, Imel, and Wampold (2008, Clinical Psychology Review, 28, 746-758) concluded that all bona fide treatments are equally effective in posttraumatic stress disorder (PTSD). In contrast, seven other meta-analyses or systematic reviews concluded that there is good evidence that trauma-focused psychological treatments (trauma-focused cognitive behavior therapy and eye movement desensitization and reprocessing) are effective in PTSD; but that treatments that do not focus on the patients' trauma memories or their meanings are either less effective or not yet sufficiently studied. International treatment guidelines therefore recommend trauma-focused psychological treatments as first-line treatments for PTSD. We examine possible reasons for the discrepant conclusions and argue that (1) the selection procedure of the available evidence used in Benish et al.'s (2008)meta-analysis introduces bias, and (2) the analysis and conclusions fail to take into account the need to demonstrate that treatments for PTSD are more effective than natural recovery. Furthermore, significant increases in effect sizes of trauma-focused cognitive behavior therapies over the past two decades contradict the conclusion that content of treatment does not matter. To advance understanding of the optimal treatment for PTSD, we recommend further research into the active mechanisms of therapeutic change, including treatment elements commonly considered to be non-specific. We also recommend transparency in reporting exclusions in meta-analyses and suggest that bona fide treatments should be defined on empirical and theoretical grounds rather than by judgments of the investigators' intent.

Psychotherapies for trauma and substance abuse in women: review and policy implications

Women are subject to high rates of interpersonal violence. One frequent co-occurring issue is substance abuse, which may arise posttrauma as a way to cope. In this article, psychosocial therapies for co-occurring trauma and substance abuse are reviewed. Description of empirically studied models is provided, as well as results of the empirical studies. Overall, this area of work suggests positive growth in the availability of new models but very limited empirical work thus far for all but one model. Directions for the future include the need for greater study of treatments in this area, as well as the need to address issues beyond specific models (e.g., workforce issues, access to care, and changing the culture of treatment systems). Policy implications are also offered.