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Sippel LM, Wachsman TR, Kelley ME, Knopp KC, Khalifian CE, Maglione JE, Glynn SM, Macdonald A, Monson CM, Flanagan JC, Holtzheimer PE, Morland LA. Design of a randomized clinical trial of brief couple therapy for PTSD augmented with intranasal oxytocin. Contemp Clin Trials 2024; 141:107534. [PMID: 38614447 DOI: 10.1016/j.cct.2024.107534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 04/02/2024] [Accepted: 04/10/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Leveraging military veterans' intimate relationships during treatment has the potential to concurrently improve posttraumatic stress disorder (PTSD) symptoms and relationship quality. Cognitive-Behavioral Conjoint Therapy (CBCT) and an 8-session Brief Cognitive-Behavioral Conjoint Therapy (bCBCT) are manualized treatments designed to simultaneously improve PTSD and relationship functioning for couples in which one partner has PTSD. Although efficacious in improving PTSD, the effects of CBCT on relationship satisfaction are small, especially among veterans. Intranasal oxytocin, which targets mechanisms of PTSD and relationship quality, may enhance the efficacy of bCBCT. METHOD/DESIGN The purpose of this 4-year clinical trial is to compare the outcomes of bCBCT augmented with intranasal oxytocin versus bCBCT plus placebo. We will also explore potential mechanisms of action: self-reported communication skills, empathy, and trust. We will recruit 120 dyads (i.e., veteran with PTSD and their intimate partner) from the VA San Diego Healthcare System. Veterans will be administered 40 international units of oxytocin (n = 60) or placebo (n = 60) 30 min before each of 8 bCBCT sessions delivered via telehealth. Clinical and functioning outcomes will be assessed at five timepoints (baseline, mid-treatment, post-treatment, and 3- and 6-month follow-up). CONCLUSION Study findings will reveal the efficacy of oxytocin-assisted brief couple therapy for PTSD, which could serve as highly scalable option for couples coping with PTSD, as well as provide preliminary evidence of interpersonal mechanisms of change. CLINICALTRIALS govIdentifier:NCT06194851.
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Affiliation(s)
- Lauren M Sippel
- Department of Veterans Affairs Northeast Program Evaluation Center, 950 Campbell Avenue, West Haven, CT 06516, USA; Department of Psychiatry, Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH 03755, USA; Department of Veterans Affairs National Center for PTSD Evaluation Division, 950 Campbell Avenue, West Haven, CT 06516, USA.
| | - Tamara R Wachsman
- Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, USA.
| | - Mary E Kelley
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health at Emory University, Atlanta, GA 30322, USA; Department of Veterans Affairs National Center for PTSD Executive Division, 215 North Main St., White River Junction, VT 05009, USA.
| | - Kayla C Knopp
- Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, La Jolla, CT 92093, USA.
| | - Chandra E Khalifian
- Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, La Jolla, CT 92093, USA.
| | - Jeanne E Maglione
- Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, La Jolla, CT 92093, USA.
| | - Shirley M Glynn
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA 90073, USA; Semel Institute for Neuroscience and Human Behavior, University of California, 760 Westwood Plaza, Los Angeles, CA 90024, USA.
| | - Alexandra Macdonald
- The Citadel, Military College of South Carolina, 171 Moultrie Street, Charleston, SC 29409, USA.
| | - Candice M Monson
- Toronto Metropolitan University, 350 Victoria Street, Toronto, Ontario M5B 2K3, Canada.
| | - Julianne C Flanagan
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, Charleston, SC 29425, USA; Ralph H. Johnson Veterans Affairs Health Care System, 109 Bee Street, Charleston, SC 29401, USA.
| | - Paul E Holtzheimer
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH 03755, USA; Department of Veterans Affairs National Center for PTSD Executive Division, 215 North Main St., White River Junction, VT 05009, USA.
| | - Leslie A Morland
- Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, USA; Department of Veterans Affairs National Center for PTSD Women's Health Sciences Division, 150 South Huntington Street, Boston, MA 02130, USA.
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Monson CM, Pukay-Martin ND, Wagner AC, Crenshaw AO, Blount TH, Schobitz RP, Dondanville KA, Young-McCaughan S, Mintz J, Riggs DS, Brundige A, Hembree EA, Litz BT, Roache JD, Yarvis JS, Peterson AL. Cognitive-behavioural conjoint therapy versus prolonged exposure for PTSD in military service members and veterans: results and lessons from a randomized controlled trial. Eur J Psychotraumatol 2024; 15:2330305. [PMID: 38590124 PMCID: PMC11005874 DOI: 10.1080/20008066.2024.2330305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/03/2024] [Indexed: 04/10/2024] Open
Abstract
Military personnel and veterans are at heightened risk for exposure to traumatic events and posttraumatic stress disorder (PTSD), as well as intimate relationship problems associated with PTSD. The purpose of this study was to evaluate the relative efficacy of CBCT and PE in improving intimate relationship functioning in active duty military personnel or veterans and their intimate partners; both conditions were hypothesized to significantly improve PTSD. Method: In this study, 32 military service members or veterans with PTSD and their intimate partners were randomized to receive either Cognitive-Behavioral Conjoint Therapy for PTSD (n = 15; CBCT; [Monson, C. M., & Fredman, S. J. (2012). Cognitive-behavioral conjoint therapy for posttraumatic stress disorder: Harnessing the healing power of relationships. Guilford]), a trauma-focused couple therapy, or Prolonged Exposure (n = 17; PE; [Foa, E. B., Hembree, E. A., Dancu, C. V., Peterson, A. L., Cigrang, J. A., & Riggs, D. S. (2008). Prolonged exposure treatment for combat-related stress disorders - provider's treatment manual [unpublished]. Department of Psychiatry, University of Pennsylvania]), a front-line evidence-based individual treatment for PTSD. There were significant challenges with recruitment and a significant difference in dropout from treatment for the two therapies (65% for PE; 27% for CBCT). Treatment dropout was differentially related to pre-treatment relationship functioning; those with below average relationship functioning had higher dropout in PE compared with CBCT, whereas those with above average relationship functioning did not show differential dropout. In general, CBCT led to relational improvements, but this was not consistently found in PE. Clinician- and self-reported PTSD symptoms improved with both treatments. This study is the first to test a couple or family therapy against a well-established, front-line recommended treatment for PTSD, with expected superiority of CBCT over PE on relationship outcomes. Lessons learned in trial design, including considerations of equipoise, and the effects of differential dropout on trial analyses are discussed. This trial provides further support for the efficacy of CBCT in the treatment of PTSD and enhancement of intimate relationships.
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Affiliation(s)
- Candice M. Monson
- Department of Psychology, Toronto Metropolitan University, Toronto, Canada
| | | | - Anne C. Wagner
- Department of Psychology, Toronto Metropolitan University, Toronto, Canada
- Remedy, Toronto, Canada
| | | | - Tabatha H. Blount
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Richard P. Schobitz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Katherine A. Dondanville
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX, USA
- Department of Population Health Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - David S. Riggs
- Hérbert School of Medicine, Uniformed Services University of the Health Sciences, and Center for Deployment Psychology, Bethesda, MD, USA
| | - Antoinette Brundige
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | | | - Brett T. Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychological and Brain Sciences, Boston University, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - John D. Roache
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Jeffrey S. Yarvis
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, TX, USA
| | - Alan L. Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX, USA
- Department of Psychology, University of Texas at San Antonio, San Antonio, TX, USA
| | - for the STRONG STAR Consortium
- Department of Psychology, Toronto Metropolitan University, Toronto, Canada
- Cincinnati VA Medical Center, Cincinnati, OH, USA
- Remedy, Toronto, Canada
- Kennesaw State University, Kennesaw, GA, USA
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Hérbert School of Medicine, Uniformed Services University of the Health Sciences, and Center for Deployment Psychology, Bethesda, MD, USA
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychological and Brain Sciences, Boston University, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX, USA
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, TX, USA
- Department of Psychology, University of Texas at San Antonio, San Antonio, TX, USA
- Department of Population Health Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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van Stolk-Cooke K, Price M, Dyar C, Zimmerman L, Kaysen D. Associations of past-year overall trauma, sexual assault and PTSD with social support for young adult sexual minority women. Eur J Psychotraumatol 2024; 15:2287911. [PMID: 38293771 PMCID: PMC10833114 DOI: 10.1080/20008066.2023.2287911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 11/11/2023] [Indexed: 02/01/2024] Open
Abstract
Background: Young adult sexual minority women (SMW) are at elevated risk for sexual assault (SA), posttraumatic stress disorder (PTSD), and inadequate social support. While SA and PTSD can lead to reductions in social support from close significant others, the impact of SA and PTSD on SMWs' social support has not previously been assessed.Objective: This study examined the associations of past year SA and PTSD with SMW's social support from intimate partners, family, and friends. It was hypothesized that SA and PTSD would be negatively associated with support from partners, family and friends, and that PTSD would moderate the effect of SA on support in early adulthood.Method: Young adult SMW in the United States (N = 235) who were M = 23.93 (SD = 2.15) years old, primarily lesbian or bisexual (n = 186, 79.1%) and White (n = 176, 74.9%) completed measures on past year exposure to SA and non-SA trauma, PTSD, and social support from intimate partners, family and friends.Results: PTSD was associated with less social support from partners, (b = -0.06, SE = 0.02, p = .010, R2change = .02), family, (b = -0.06, SE = 0.03, p = .025, R2change = .02), and friends, (b = -0.07, SE = 0.02, p = .008, R2change = .02). There was a significant interaction between PTSD and SA on social support from partners (b = -0.01, SE = 0.01, p = .047, R2change = .01). Neither non-SA nor SA trauma was associated with support from family or friends.Conclusions: Results underscore the potential impact of recent SA on intimate partnerships for young adult SMW with more severe PTSD. Future work should explore how addressing PTSD and improving social support quality may help SMW recover from traumatic experiences and ameliorate the effects of SA on intimate partnerships.
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Affiliation(s)
- Katherine van Stolk-Cooke
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
- Psychology Department, State University of New York (SUNY Geneseo), Geneseo, NY, USA
| | - Mathew Price
- Department of Psychological Sciences, University of Vermont, Burlington, VT, USA
| | - Christina Dyar
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Lindsey Zimmerman
- National Center for PTSD, Dissemination and Training Division, Palo Alto, CA, USA
| | - Debra Kaysen
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
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Dodge J, Sullivan K, Grau PP, Chen C, Sripada R, Pfeiffer PN. Retention in Individual Trauma-Focused Treatment Following Family-Based Treatment Among US Veterans. JAMA Netw Open 2023; 6:e2349098. [PMID: 38127345 PMCID: PMC10739069 DOI: 10.1001/jamanetworkopen.2023.49098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023] Open
Abstract
Importance Despite the availability of several empirically supported trauma-focused interventions, retention in posttraumatic stress disorder (PTSD) psychotherapy is poor. Preliminary efficacy data shows that brief, family-based interventions may improve treatment retention in a veteran's individual PTSD treatment, although whether this occurs in routine clinical practice is not established. Objective To characterize receipt of family therapy among veterans diagnosed with PTSD and evaluate whether participation in family therapy is associated with an increased likelihood of completing individual trauma-focused treatment. Design, Setting, and Participants This retrospective cohort study used the Veterans Health Administration (VHA) Informatics and Computing Infrastructure to extract electronic health record data of participants. All participants were US veterans diagnosed with PTSD between October 1, 2015, and December 31, 2019, who attended at least 1 individual trauma-focused treatment session. Statistical analysis was performed from May to August 2023. Exposures Receipt of any family psychotherapy and subtype of family-based psychotherapy. Main Outcomes and Measures Minimally adequate individual trauma-focused treatment completion (ie, 8 or more sessions of trauma-focused treatment in a 6-month period). Results Among a total of 1 516 887 US veterans with VHA patient data included in the study, 58 653 (3.9%) received any family therapy; 334 645 (23.5%) were Black, 1 006 168 (70.5%) were White, and 86 176 (6.0%) were other race; 1 322 592 (87.2%) were male; 1 201 902 (79.9%) lived in urban areas; and the mean (SD) age at first individual psychotherapy appointment was 52.7 (15.9) years. Among the 58 653 veterans (3.9%) who received any family therapy, 36 913 (62.9%) received undefined family therapy only, 15 528 (26.5%) received trauma-informed cognitive-behavioral conjoint therapy (CBCT) only, 5210 (8.9%) received integrative behavioral couples therapy (IBCT) only, and 282 (0.5%) received behavioral family therapy (BFT) only. Compared with receiving no family therapy, the odds of completing individual PTSD treatment were 7% higher for veterans who also received CBCT (OR, 1.07 [95% CI, 1.01-1.13]) and 68% higher for veterans received undefined family therapy (OR, 1.68 [95% CI, 1.63-1.74]). However, compared with receiving no family therapy care, veterans had 26% lower odds of completing individual PTSD treatment if they were also receiving IBCT (OR, 0.74 [95% CI, 0.66-0.82]). Conclusions and Relevance In this cohort study of US veterans, family-based psychotherapies were found to differ substantially in their associations with individual PTSD psychotherapy retention. These findings highlight potential benefits of concurrently providing family-based therapy with individual PTSD treatment but also the need for careful clinical attention to the balance between family-based therapies and individual PTSD treatment.
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Affiliation(s)
- Jessica Dodge
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
| | | | - Peter P. Grau
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Charity Chen
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
| | - Rebecca Sripada
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Paul N. Pfeiffer
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
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Brewerton TD. The integrated treatment of eating disorders, posttraumatic stress disorder, and psychiatric comorbidity: a commentary on the evolution of principles and guidelines. Front Psychiatry 2023; 14:1149433. [PMID: 37252137 PMCID: PMC10213703 DOI: 10.3389/fpsyt.2023.1149433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 04/18/2023] [Indexed: 05/31/2023] Open
Abstract
Psychiatric comorbidity is the norm in the assessment and treatment of eating disorders (EDs), and traumatic events and lifetime PTSD are often major drivers of these challenging complexities. Given that trauma, PTSD, and psychiatric comorbidity significantly influence ED outcomes, it is imperative that these problems be appropriately addressed in ED practice guidelines. The presence of associated psychiatric comorbidity is noted in some but not all sets of existing guidelines, but they mostly do little to address the problem other than referring to independent guidelines for other disorders. This disconnect perpetuates a "silo effect," in which each set of guidelines do not address the complexity of the other comorbidities. Although there are several published practice guidelines for the treatment of EDs, and likewise, there are several published practice guidelines for the treatment of PTSD, none of them specifically address ED + PTSD. The result is a lack of integration between ED and PTSD treatment providers, which often leads to fragmented, incomplete, uncoordinated and ineffective care of severely ill patients with ED + PTSD. This situation can inadvertently promote chronicity and multimorbidity and may be particularly relevant for patients treated in higher levels of care, where prevalence rates of concurrent PTSD reach as high as 50% with many more having subthreshold PTSD. Although there has been some progress in the recognition and treatment of ED + PTSD, recommendations for treating this common comorbidity remain undeveloped, particularly when there are other co-occurring psychiatric disorders, such as mood, anxiety, dissociative, substance use, impulse control, obsessive-compulsive, attention-deficit hyperactivity, and personality disorders, all of which may also be trauma-related. In this commentary, guidelines for assessing and treating patients with ED + PTSD and related comorbidity are critically reviewed. An integrated set of principles used in treatment planning of PTSD and trauma-related disorders is recommended in the context of intensive ED therapy. These principles and strategies are borrowed from several relevant evidence-based approaches. Evidence suggests that continuing with traditional single-disorder focused, sequential treatment models that do not prioritize integrated, trauma-focused treatment approaches are short-sighted and often inadvertently perpetuate this dangerous multimorbidity. Future ED practice guidelines would do well to address concurrent illness in more depth.
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Swerdlow BA, Baker SN, Leifker FR, Straud CL, Rozek DC, Sippel LM. The impact of trauma-focused psychotherapy for posttraumatic stress disorder on interpersonal functioning: A systematic review and meta-analysis of randomized clinical trials. J Trauma Stress 2023. [PMID: 36628929 DOI: 10.1002/jts.22906] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 10/27/2022] [Accepted: 11/14/2022] [Indexed: 01/12/2023]
Abstract
Interpersonal functioning is a common concern for people with postttraumatic stress disorder (PTSD) but is not a key target of most trauma-focused psychotherapies (TFPs). We preregistered and undertook a systematic review and meta-analysis of randomized clinical trials (RCTs) examining the efficacy of TFPs for improving interpersonal functioning. Studies were identified through the PTSD Trials Standardized Data Repository, scholarly databases, and the solicitation of unpublished data from the PTSD research community following current PRISMA guidelines. We used random effects meta-analysis to estimate within-group change (i.e., pre- to posttreatment) in interpersonal functioning. Meta-analytic findings yielded a medium total effect of TFP on interpersonal functioning, g = 0.54, 95% CI [0.37, 0.72], with high between-study heterogeneity. Sensitivity analyses yielded substantively equivalent point estimates when outliers were excluded, g = 0.55, and when only the most well-established individual TFPs were included, g = 0.57. In contrast, allocation to a control condition was associated with little average change in interpersonal functioning, g = 0.04 [-0.12, 0.21]. Formal tests did not yield clear evidence of publication bias. Bias-corrected estimates varied but centered around a medium effect, gs = 0.41-1.11. There was a medium-to-large association between change in interpersonal functioning and change in PTSD symptoms, rs = -.35--.44. The extant literature on TFPs and interpersonal functioning is small and heterogeneous, indicating the need for more focused attention on this outcome. Results suggest that, on average, TFPs are moderately efficacious for improving interpersonal functioning; however, additional treatment may be needed to meet the desired level of improvement.
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Affiliation(s)
| | - Shelby N Baker
- Department of Psychology, University of Central Florida, Orlando, Florida, USA
| | - Feea R Leifker
- Department of Psychology, University of Utah, Salt Lake City, Utah, USA
| | - Casey L Straud
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.,Department of Psychology, University of Texas at San Antonio, San Antonio, Texas, USA.,South Texas Veterans Healthcare System, San Antonio, Texas, USA
| | - David C Rozek
- Department of Psychology, University of Central Florida, Orlando, Florida, USA.,Department of Psychology, University of Utah, Salt Lake City, Utah, USA
| | - Lauren M Sippel
- Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, Connecticut, USA.,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.,Department of Veterans Affairs National Center for PTSD, West Haven, Connecticut, USA
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