Ten misconceptions about trauma-focused CBT for PTSD

A systematic review and meta-analysis of PTSD symptoms at mid-treatment during trauma-focused treatment for PTSD

There is concern that trauma memory processing in psychological therapies leads to PTSD symptom exacerbation. We compared PTSD symptoms at mid-treatment in trauma-focused psychological therapy to control groups. We systematically searched multiple databases and searched grey literature. We included randomised controlled trials involving adults comparing trauma-focused psychological interventions with active non-trauma-focused interventions or waitlist conditions. Twenty-three studies met our inclusion criteria. We found no evidence of PTSD symptom exacerbation at mid-treatment in trauma-focused interventions compared to control groups (g=-.16, [95 % confidence interval, CI, -.34,.03]). Sensitivity analyses with high quality studies (risk of bias assessment ≥ 7; g=-.25; [95 % CI -.48, -.03], k = 12) and studies with passive controls (g=-.32; [95 % CI -.59, -.05], k = 8) yielded small effect sizes favouring trauma-focused interventions. At post-treatment, trauma-focused interventions yielded a medium effect on PTSD symptoms compared to all controls (g=-.57; [CI -.79, -.35], k = 23). Regarding depression, trauma-focused interventions yielded a small effect size compared to controls at mid-treatment (g=-.23; [95 % CI -.39, -.08], k = 12) and post-treatment (g=-.45; [CI -.66, -.25], k = 12). This meta-analysis found no evidence that trauma-focused psychotherapies elicit symptom exacerbation at mid-treatment in terms of PTSD or depression symptoms. Instead, this meta-analysis suggests that the benefits of trauma-focused interventions can be experienced through improved depression and possibly PTSD before the conclusion of therapy. However, it is possible that symptom exacerbation occurred before mid-treatment and/or that people who experience symptom exacerbation drop out of studies and so are not included in the analysis.

Enhancing Agency in Posttraumatic Stress Disorder Therapies Through Sensorimotor Technologies

Posttraumatic stress disorder (PTSD) is a significant public health concern, with only a third of patients recovering within a year of treatment. While PTSD often disrupts the sense of body ownership and sense of agency (SA), attention to the SA in trauma has been lacking. This perspective paper explores the loss of the SA in PTSD and its relevance in the development of symptoms. Trauma is viewed as a breakdown of the SA, related to a freeze response, with peritraumatic dissociation increasing the risk of PTSD. Drawing from embodied cognition, we propose an enactive perspective of PTSD, suggesting therapies that restore the SA through direct engagement with the body and environment. We discuss the potential of agency-based therapies and innovative technologies such as gesture sonification, which translates body movements into sounds to enhance the SA. Gesture sonification offers a screen-free, noninvasive approach that could complement existing trauma-focused therapies. We emphasize the need for interdisciplinary collaboration and clinical research to further explore these approaches in preventing and treating PTSD.

State of the Science: Evidence-based treatments for posttraumatic stress disorder delivered via telehealth

Psychotherapy delivered via telehealth technology is not an artifact of the COVID-19 pandemic. Indeed, widespread, telehealth-delivered, evidence-based psychotherapy preceded the pandemic, as did randomized controlled noninferiority trials supporting this modality. It is, thus, not difficult to predict that telehealth will be an integral part of daily clinical life moving forward. With respect to posttraumatic stress disorder (PTSD) specifically, there is a substantial number of studies on the feasibility, acceptability, and effectiveness of evidence-based treatments provided via videoconferencing. In this review, we delineate the literature establishing strong support for remote delivery of prolonged exposure (PE) and cognitive processing therapy (CPT); there is also promising support for written exposure therapy (WET) and trauma-focused cognitive behavioral therapy (TF-CBT). We also mention adjunctive and integrative modifications to better serve patients with PTSD. One such intervention, behavioral activation and therapeutic exposure (BATE), has several studies supporting telehealth delivery, whereas concurrent treatment of PTSD and substance use disorders using the PE protocol (COPE) and cognitive behavioral therapy for insomnia (CBT-I) would benefit from further research. Integrating instrumental peer support into telehealth-delivered PE shows promise in retaining patients in treatment. Finally, we provide ideas to maximize telehealth delivery effectiveness, explore future research directions, and discuss ways to advocate for the expansion of telehealth services from an equity perspective.

Individual treatment selection for patients with post-traumatic stress disorder: External validation of a personalised advantage index

OBJECTIVE

To test the predictive accuracy and generalisability of a personalised advantage index (PAI) model designed to support treatment selection for Post-Traumatic Stress Disorder (PTSD).

METHOD

A PAI model developed by Deisenhofer et al. (2018) was used to predict treatment outcomes in a statistically independent dataset including archival records for N = 152 patients with PSTD who accessed either trauma-focussed cognitive behavioural therapy or eye movement desensitisation and reprocessing in routine care. Outcomes were compared between patients who received their PAI-indicated optimal treatment versus those who received their suboptimal treatment.

RESULTS

The model did not yield treatment specific predictions and patients who had received their PAI-indicated optimal treatment did not have better treatment outcomes in this external validation sample.

CONCLUSION

This PAI model did not generalise to an external validation sample.

The future of psychological treatments: The Marburg Declaration

Although psychological treatments are broadly recognized as evidence-based interventions for various mental disorders, challenges remain. For example, a substantial proportion of patients receiving such treatments do not fully recover, and many obstacles hinder the dissemination, implementation, and training of psychological treatments. These problems require those in our field to rethink some of our basic models of mental disorders and their treatments, and question how research and practice in clinical psychology should progress. To answer these questions, a group of experts of clinical psychology convened at a Think-Tank in Marburg, Germany, in August 2022 to review the evidence and analyze barriers for current and future developments. After this event, an overview of the current state-of-the-art was drafted and suggestions for improvements and specific recommendations for research and practice were integrated. Recommendations arising from our meeting cover further improving psychological interventions through translational approaches, improving clinical research methodology, bridging the gap between more nomothetic (group-oriented) studies and idiographic (person-centered) decisions, using network approaches in addition to selecting single mechanisms to embrace the complexity of clinical reality, making use of scalable digital options for assessments and interventions, improving the training and education of future psychotherapists, and accepting the societal responsibilities that clinical psychology has in improving national and global health care. The objective of the Marburg Declaration is to stimulate a significant change regarding our understanding of mental disorders and their treatments, with the aim to trigger a new era of evidence-based psychological interventions.

The efficacy of psychological interventions for adult post-traumatic stress disorder following exposure to single versus multiple traumatic events: a meta-analysis of randomised controlled trials

BACKGROUND

Previous meta-analyses of psychological interventions for adult post-traumatic stress disorder (PTSD) did not investigate whether efficacy is diminished in individuals with PTSD related to multiple (vs single) traumatic events. We aimed to assess whether treatment efficacy would be lower in randomised controlled trials involving multiple-event-related PTSD versus single-event-related PTSD.

METHODS

For this meta-analysis, we searched PsycINFO, MEDLINE, Web of Science, and PTSDpubs from database inception to April 18, 2023. Randomised controlled trials involving adult clinical samples (≥70% meeting full PTSD criteria) with adequate size (≥10 participants per arm) were included. We extracted data on trial characteristics, demographics, and outcome data. Random-effects meta-analyses were run to summarise standardised mean differences (Hedges' g). Trials involving 100% of participants with single-event-related PTSD versus at least 50% of participants with multiple-event-related PTSD (ie, associated with ≥two traumatic events) were categorised. Quality of evidence was assessed using the Cochrane criteria. The review protocol was registered in PROSPERO (CRD42023407754).

FINDINGS

Overall, 137 (85%) of 161 randomised controlled trials were included in the quantitative synthesis, comprising 10 684 participants with baseline data and 9477 with post-treatment data. Of those randomly assigned, 5772 (54%) of 10 692 participants identified as female, 4917 (46%) as male, and three (<1%) as transgender or other. 34 (25%) of 137 trials exclusively involved women, 15 (11%) trials exclusively involved men, and the remainder were mixed samples. Mean age across the trials was 40·2 years (SD 9·0) ranging from 18·0 years to 65·4 years. 23 (17%) of 137 trials involved participants from low-income and middle-income countries (23 [17%] of 137). Data on ethnicity were not extracted. At treatment endpoint, psychological interventions were highly effective for PTSD when compared with passive control conditions in both samples with single-event-related PTSD (Hedges' g 1·04 [95% CI 0·77-1·31]; n=11; I2=43%) and multiple-event-related PTSD (Hedges' g 1·13 [0·90-1·35]; n=55, I2=87%), with no efficacy difference between these categories (p=0·48). Heterogeneity between studies was substantial but outlier-corrected analysis yielded similar results. Moderate-sized effects were found compared with active control conditions with no significant difference between single-trauma and multiple-trauma trials. Results were robust in various sensitivity analyses (eg, 90% cutoff for multiple-trauma trials) and analyses of follow-up data. The quality of evidence was moderate to high.

INTERPRETATION

Contrary to our hypothesis, we found strong evidence that psychological interventions are highly effective treatments for PTSD in patients with a history of multiple traumatic events. Results are encouraging for clinical practice and could counteract common misconceptions regarding treatment and treatment barriers.

FUNDING

None.

Trauma-Informed Care in Psychedelic Therapy Research: A Qualitative Literature Review of Evidence-Based Psychotherapy Interventions in PTSD and Psychedelic Therapy Across Conditions

Introduction

Post-traumatic stress disorder (PTSD) is associated with significant patient burden. While pharmacotherapies and evidence-based psychotherapy interventions (EBPI) are effective, studies consistently highlight inadequate outcomes and high treatment dropout. Psychedelic therapy (PT) has shown preliminary promise across difficult-to-treat conditions, including MDMA-assisted therapy for PTSD, however trials of classical psychedelics in PTSD are lacking. Understanding patients' experiences of EBPI could help promote safety in PT.

Aim

To systematically review qualitative research on patients' subjective experience of EBPI for PTSD, and of PT, and examine areas of overlap and divergence between them.

Methods

Systematic literature searches for studies published between 2010 and 2023 were conducted on OVID, PubMed, Web of Science, and PsycInfo. Included were original studies in English that presented qualitative data of patient experiences of EBPI in PTSD, or PT for any indication. Extracted data from included studies were analysed using thematic synthesis. Syntheses were completed separately for EBPI and PT, before similarities and differences between the therapies were identified.

Results

40 research articles were included for review: 26 studies on EBPI for PTSD, and 14 studies on PT. EBPI studied were CBT, EMDR, CPT and PE. Psychedelic compounds studied were psilocybin, ibogaine, LSD, MDMA and ketamine, for treatment of substance use disorders, anxiety relating to physical illness, depression, and PTSD. Core themes from patient experiences of EBPI: 1) patient burden in PTSD treatment; 2) readiness; 3) key mechanisms of change; 4) psychological safety and trust. Themes identified in the review of PT: 1) indirect trauma processing; 2) reorganisation of self-narratives via processes of relatedness and identification; 3) key treatment characteristics.

Conclusion

This study suggests overlap between patients' experience of EBPI and PT in terms of key mechanisms of change, the importance of psychological safety and readiness to engage in treatment. Trauma-informed care paradigms and practices may improve safety and acceptability of PT research.

Maladaptive therapist schemas in CBT practice, training and supervision: A scoping review

BACKGROUND

Maladaptive therapist schemas are hypothesized to generate difficulties within cognitive behavioural therapy (CBT) practice, training and supervision. Without adequate identification and management, they negatively affect the cognitions and emotions of the therapist, leading them to behave in ways that risk ruptures or therapy and supervision being delivered in a suboptimal fashion. Consequently, there is a need to synthesize the research that has been undertaken to date on the content, prevalence, identification and management of maladaptive therapist schemas.

METHOD

A scoping review was undertaken of studies that have been published since 2001 on the impact of maladaptive therapist schemas (also referred to interchangeably as beliefs or cognitions) in CBT practice, training and supervision. Thirteen studies were identified in a literature search from four electronic databases, a reference list search of identified articles and hand searches.

RESULTS

Three overall themes were identified in the research: (1) prevalence of therapist schemas, (2) specific therapist beliefs and (3) therapist characteristics associated with the delivery of suboptimal CBT or supervision. While there is little empirical support for therapist schemas, therapist resistance and beliefs relating to the fear of using exposure therapy were identified. Therapist intolerance of uncertainty and self-esteem were recurrent factors.

CONCLUSION

There is no consensus on how to define, identify, formulate or respond to maladaptive therapist beliefs or schemas in clinical practice, training or supervision. Further research is needed to better understand their origins, maintaining factors and appropriate management of their impact.