Therapist use of cognitive behavior therapy and eye movement desensitization and reprocessing components for the treatment of posttraumatic stress disorder in practice settings

Introduction

Treatment practice guidelines for posttraumatic stress disorder (PTSD) recommend both Eye Movement Desensitization and Reprocessing (EMDR) and Cognitive Behavior Therapy (CBT); however, implementation in practice setting remains challenging. Here we aim to foster implementation efforts for PTSD by identifying the relative use of the various components of empirically supported treatments by therapists and the characteristics that predict their use.

Methods

Surveyed 346 therapists (84.07% female) of whom 272 participants (78.61%) were trained primarily in CBT and 135 participants (39.02%) were trained in primarily in EMDR. Assessed relative use of various EMDR and CBT components as well as several training and personality factors.

Results

Psychoeducation about trauma was the most common element used. "Off label" use of components was also identified with application of EMDR techniques to other diagnoses. Findings also suggest underutilization of in vivo exposure techniques across therapists. EMDR therapists reported relatively high use of core EMDR techniques (i.e., greater use of EMDR core techniques). Big five personality factors, therapy efficacy, and anxiety were associated with differential component use.

Discussion

Results identify trends in empirically supported component use and therapist characteristics that are associated with the use of various techniques for PTSD. The findings suggest implementation efforts could foster training in underused techniques, address barriers to their utilization and develop knowledge of effective packages of components.

Posttraumatic Stress Disorder, Anxiety, and Depression Symptoms After Potentially Traumatic Events: Latent Classes and Cognitive Correlates

People exposed to potentially traumatic events (PTEs) may develop distinct symptom patterns, which may require different therapeutic approaches. We aimed to identify classes of people exposed to PTEs based on the presence of posttraumatic stress disorder (PTSD) clusters, anxiety, and depression and to explore which cognitive factors (rumination, worry, and negative cognitions) are associated with class membership. Latent class analyses were conducted to identify subgroups of 258 PTE-exposed Spanish adults. A three-class solution emerged: a resilient class with low odds of all symptoms ( n = 188); a partial PTSD class, characterized by partial PTSD clusters, moderate anxiety, and low depression ( n = 36); and a high symptom class, characterized by high PTSD, moderate anxiety, and low depression ( n = 34). These classes related meaningfully to rumination, worry, and negative cognitions. Distinct symptom patterns of PTSD clusters, anxiety, and depression can be distinguished in people exposed to PTEs and relate to cognitive risk factors of psychopathology.

A Systematic Chart Review of Adults with Post-Traumatic Stress Disorder: Data from a Tertiary Care Psychiatry Center in India

BACKGROUND

Post-traumatic stress disorder (PTSD) is an understudied construct in the psychiatric setting. The majority of existing Indian studies on PTSD focus on the general population or disaster-stricken communities. Here, we present data from a five-year retrospective chart review from a tertiary care psychiatric center in India.

METHODS

Medical records of adult patients (≥18 years) who had attended psychiatry outpatient services between April 1, 2015 and March 31, 2020 (five years) and were diagnosed with PTSD, as per ICD-10 criteria, were reviewed (n = 113). The relevant sociodemographic and clinical details were extracted using a semistructured pro-forma.

RESULTS

The percentage of adult patients with PTSD diagnosis in the five years was 0.22%. PTSD was more common in females (n = 65, 57.5%). Most patients had interpersonal trauma (n = 85, 75.2%), specifically sexual abuse (n = 47, 41.6%). The median age of onset was 22 years. All the patients had re-experiencing symptoms, with an equally high rate of avoidance (n = 109, 96.5%) and arousal symptoms (n = 110, 97.3%). 82%(93) had a comorbid psychiatric disorder, with mood disorder being the most common (n = 44, 38.9%). Males had a higher rate of comorbid substance use disorder (n = 14, 29.2%) and depression (n = 20,42%), and females had a higher rate of comorbid dissociative disorder (n = 13,20%). Most of the patients received non-trauma-focused psychological interventions, and only 18% (20) received evidence-based trauma-focused psychological interventions.

CONCLUSION

Interpersonal trauma, specifically sexual abuse, largely contributes to PTSD among adults attending psychiatric services. The need for trauma-focused psychological interventions is underscored.

Bridging the science-practice gap in treatment for posttraumatic stress disorder: Testing strategies to enhance beliefs toward exposure therapy

OBJECTIVE

Exposure therapies (e.g., prolonged exposure [PE]), are first-line interventions for posttraumatic stress disorder but remain underutilized, partially due to providers' negative beliefs about these interventions. We examined two experimental strategies aimed at enhancing beliefs towards PE and subsequent utilization.

METHOD

Clinicians (N = 155) were randomized to one of three conditions presenting a PE rationale: basic, empirically-based, or emotionally-based description. Participants were rerandomized to write or not write arguments for utilizing PE. Before and after PE rationales and 1-month later, participants completed questions about PE beliefs and utilization.

RESULTS

Participants reported small yet durable belief change across all rationale conditions, with greatest change following the empirically-based description. Across conditions, belief change was not impacted by writing condition or associated with utilization.

CONCLUSION

Addressing negative beliefs with empirical information may be a brief, cost-effective strategy to improve clinicians' beliefs toward PE. Complementary strategies that leverage belief modification to increase utilization are needed.

The Research-Practice Psychotherapy Wars: The Case of Group Psychotherapy in the Treatment of PTSD

In light of two recent meta-analyses of the efficacy of group psychotherapy in treating posttraumatic stress disorder (PTSD), this article critically reviews the randomized control trial (RCT) generated findings as well as two of its outgrowths-the production of a variety of clinical practice guidelines for treating PTSD and the dissemination efforts to transfer laboratory findings to clinical practice. All three of these activities have received considerable pushback from experienced clinicians and Boulder-identified scientist practitioners, creating an ongoing and entrenched gap or split between researcher and clinician. The article also reviews the various suggestions that have been offered to heal this gap and ending the hegemony of RCT outcome research as the only game in town for declaring what constitutes evidence. Specifically, the literature suggests two primary strategies for helping to realize the scientist-practitioner model and thus advancing the cause of psychotherapy, in general, and group psychotherapy, in particular: (a) leveling the playing field so that both researcher and practitioner have real authority and voices for shaping the field; and (b) shifting the research priority away from a purely outcome focus, asking only does it work, and moving to a more sophisticated, theoretically guided empirical study of process-outcome, examining the how, why, when, and for whom it works.

Patient and Therapist Perspectives on Treatment for Adults with PTSD from Childhood Trauma

This study aimed to explore patients’ and therapists’ experiences with trauma-focused treatments in patients with posttraumatic stress disorder from childhood trauma (Ch-PTSD). Semi-structured interviews were conducted with patients (n = 44) and therapists (n = 16) from an international multicentre randomised clinical trial comparing two trauma-focused treatments (IREM), imagery rescripting and eye movement and desensitisation (EMDR). Thematic analysis was used to identify key themes within the data. Patients and therapists commented about the process of therapy. The themes that emerged from these comments included the importance of the patients’ willingness to engage and commit to the treatment process; the importance and difficulty of the trauma work, observations of how the trauma focused therapy produced changes in insight, and sense of self and empowerment for the future. In addition, therapists made suggestions for optimising the therapist role in the trauma-focused treatment. This included the importance of having confidence in their own ability, confronting their own and their client’s avoidance and the necessity and difficulties of adhering to the treatment protocols. These reported experiences add further support to the idea that trauma-focused treatments, without a stabilisation phase, can be tolerated and deepens our understanding of how to make this palatable for individuals with Ch-PTSD.

Predictors of outcome during inpatient psychotherapy for posttraumatic stress disorder: a single-treatment, multi-site, practice-based study

Objective: The aims of this study were to determine the effectiveness of a routine clinical care treatment and to identify predictors of treatment outcome in PTSD inpatients. Methods: A routinely collected data set of 612 PTSD inpatients (M = 42.3 years [SD = 11.6], 75.7% female) having received trauma-focused psychotherapy was analyzed. Primary outcome was the clinical symptom severity change score, secondary outcomes were assessed using functional, anxiety, and depression change scores. Hedges g-corrected pre-post effect sizes (ES) were computed for all outcomes. Elastic net regulation as a data-driven, stability-based machine-learning approach was used to build stable clinical prediction models. Results: Hedges g ES indicated medium to large effects on all outcomes. The results of the predictor analyses suggested that a combined predictor model with sociodemographic, clinical, and psychometric variables contribute to predicting different treatment outcomes. Across the clinical and functional outcome, psychoticism, total number of diagnoses, and bronchial asthma consistently showed a stable negative predictive relationship to treatment outcome. Conclusion: Trauma-focused psychotherapy could effectively be implemented in a routine inpatient setting. Some important prognostic variables could be identified. If the proposed models of predictors are replicated, they may help personalize treatment for patients receiving routine clinical care.

Impaired hippocampus-dependent associative learning as a mechanism underlying PTSD: A meta-analysis

Smaller hippocampal volume is associated with increased risk for PTSD following trauma, but the hippocampal functions involved remain unknown. We propose a conceptual model that identifies broad impairment in hippocampus-dependent associative learning as a vulnerability factor for PTSD. Associative learning of foreground cues and background context is required to form an integrated representation of an event. People with poor associative learning may have difficulty remembering who or what was present during a trauma, where the trauma occurred, or the sequence of events, which may contribute to PTSD symptoms. We argue that associative learning difficulties in PTSD exist for cues and context, regardless of the emotional nature of the information. This contrasts with PTSD models that focus exclusively on threat-processing or contextual-processing. In a meta-analysis, people with PTSD exhibited poor associative learning of multiple information types compared to those without PTSD. Differences were of medium effect size and similar magnitude for neutral and negative/trauma-related stimuli. We provide evidence for associative learning difficulties as a neurocognitive pathway that may contribute to PTSD.

Dealing with complexity and comorbidity: Opportunity for transdiagnostic treatment for PTSD

Purpose of Review

This review synthesizes literature on transdiagnostic treatments for PTSD and trauma-related psychopathology over the last three years and discusses their across diverse contexts.

Recent Findings

Global and domestic studies suggest that a transdiagnostic approach has the potential to address many challenges providers encounter when treating traumatized populations. Existing research shows that transdiagnostic approaches (including the Unified Protocol, Common Elements Treatment Approach, and Modular Approach to Therapy for Children) are effective across low and high resourced settings, populations, and with comorbid mental health symptoms. Moreover, transdiagnostic approaches offer flexibility in treatment delivery, adaptability across contexts, and parsimonious training to treatment providers. They also provide a standalone alternative for unable or unwilling individuals to engage in traditional single diagnosis trauma-focused treatment, or those presenting with complex presentations that might otherwise require sequential courses of targeted interventions.

Summary

The promise of transdiagnostic treatment for trauma-populations is strong. Research is needed to examine patient and therapist perceptions of these approaches for optimally addressing PTSD and related symptoms, the extent to which they offer comparable, or perhaps better, outcomes than existing single diagnosis PTSD treatments, and their sustainability overtime. Considerations of adaptations to transdiagnostic treatment manuals across settings are also needed.

Improving our understanding of the relationship between emotional abuse and substance use disorders: the mediating roles of negative urgency and posttraumatic stress disorder

Background: Emotional abuse is associated with an increased risk for substance use disorders (SUDs) as well as with negative urgency and posttraumatic stress disorder (PTSD) following a subsequent trauma. Both negative urgency and PTSD are key contributors to the relationship between emotional abuse and SUDs when examined separately. A comprehensive model including both factors can inform models of PTSD-SUD comorbidity. Furthermore, the comparison of these mechanistic roles in emotional versus other types of abuse can shed light on the specificity of these effects. Objectives: The present study tested whether negative urgency and PTSD symptom severity serially mediated the relationship between emotional abuse and substance use across two separate samples. Method: Participants were recruited from a detoxification center and completed a battery of surveys examining abuse history, PTSD symptom severity, and impulsivity measures including negative urgency and substance use history during the last 3 months. The samples consisted of predominantly (59% and 62%) males with an average age of 35 (age range: 18-65). The majority of participants (90% and 93%) were Caucasian. Results: Study 1 (N = 368) and Study 2 (N = 274) both found that negative urgency and PTSD symptom severity serially mediated the relationship between emotional abuse and substance use. When comparing indirect effects, both contributed equally. Conclusion: These findings suggest that negative urgency and PTSD symptom severity together account more for the link between emotional abuse and SUDs than either alone and argue for the inclusion of negative urgency in models of PTSD-SUD comorbidity.

Dissemination of exposure in the treatment of anxiety disorders and post-traumatic stress disorder among German cognitive behavioural therapists

The efficacy of exposure is beyond doubt, which is reflected in guidelines recommending its application in the treatment of anxiety disorders and post-traumatic stress disorder (PTSD). Research suggests exposure to be underutilized in clinical practice in the United States and Europe. A systematic investigation of the dissemination of exposure in Germany is lacking. The present study examined the dissemination and application frequency of exposure among German cognitive behavioural therapists working in routine care. In an online-based survey, 331 psychotherapists provided information on treatment of patients with panic disorder, phobia, and PTSD. By means of multinomial logistic regression analysis, application frequency of exposure (non-users vs. users vs. frequent users) was predicted by various therapist characteristics. Younger age and less negative beliefs about exposure significantly predicted the affiliation to the frequent users group compared to the non-users in the treatment of panic disorder or phobia. Concerning treatment of PTSD, only negative beliefs about exposure was identified as significant predictor. Sex, educational level, and number of exposure sessions performed during clinical training were not of predictive value. Current findings suggest that negative beliefs about exposure and age impact the frequent provision of exposure to patients. Modification of negative attitudes might be achieved through specific training strategies.

Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial

The objective of this study was to test whether treatment acceptability, exposure engagement, and completion rates could be increased by integrating acceptance and commitment therapy (ACT) with traditional exposure and response prevention (ERP). 58 adults (68% female) diagnosed with obsessive-compulsive disorder (OCD; M age = 27, 80% white) engaged in a multisite randomized controlled trial of 16 individual twice-weekly sessions of either ERP or ACT + ERP. Assessors unaware of treatment condition administered assessments of OCD, depression, psychological flexibility, and obsessional beliefs at pretreatment, posttreatment, and six-month follow-up. Treatment acceptability, credibility/expectancy, and exposure engagement were also assessed. Exposure engagement was high in both conditions and there were no significant differences in exposure engagement, treatment acceptability, or dropout rates between ACT + ERP and ERP. OCD symptoms, depression, psychological inflexibility, and obsessional beliefs decreased significantly at posttreatment and were maintained at follow-up in both conditions. No between-group differences in outcome were observed using intent to treat and predicted data from multilevel modeling. ACT + ERP and ERP were both highly effective treatments for OCD, and no differences were found in outcomes, processes of change, acceptability, or exposure engagement.

Perinatal interventions for mothers and fathers who are survivors of childhood sexual abuse

Childhood sexual abuse (CSA) is a worldwide problem with severe long-term consequences. A history of CSA can impact the childbearing experience of mothers and fathers; affecting their mental health, parenting skills and compromising infant development. Nonetheless, the perinatal period offers huge opportunity for intervention and hope. This literature review collates evidence for perinatal psychosocial interventions targeting both mothers and fathers who are survivors of CSA. Publications dating from 1970 to June 2016 were searched using Medline, Maternity and Infant Health, PsychINFO, PsychArticles, PubMed and the International Bibliography of the Social Sciences (IBSS). There were no perinatal interventions that considered the needs of survivor fathers. Sixteen publications on 9 psychosocial perinatal interventions for CSA survivors were identified. However, no sub-analyses specific to CSA survivors were reported. Trauma-specific perinatal interventions drew from a range of theoretical models and varied widely in format. Generally interventions were associated with improvements in maternal mental health, parenting competence, infant attachment security and positive public health outcomes. They were safe and feasible to implement, acceptable to parents and therapist, and therapists were able to implement protocols with adequate fidelity. Yet current data is hampered by small sample size, inconsistent reporting of CSA rates and outcome measures, scarcity of observational data and longer-term follow-up. Intervention modifications are proposed for CSA survivors in view of their unique childbearing experiences.

Post-training Beliefs, Intentions, and Use of Prolonged Exposure Therapy by Clinicians in the Veterans Health Administration

To examine how changes in beliefs during the training process predict adoption of prolonged exposure therapy (PE) by veterans health administration clinicians who received intensive training in this evidence-based treatment. Participants completed a 4-day PE workshop and received expert consultation as they used PE with two or more training cases. Participants were surveyed prior to the workshop, after the workshop, after case consultation (n = 1.034), and 6 months after training (n = 810). Hierarchical regression was used to assess how pre-training factors, and changes in beliefs during different stages of training incrementally predicted post-training intent to use PE and how many patients clinicians were treating with PE 6 months after training. Post-training intent to use PE was high (mean = 6.2, SD = 0.81 on a 1-7 scale), yet most participants treated only 1 or 2 patients at a time with PE. Pre-training factors predicted intent to use and actual use of PE. Changes in beliefs during the workshop had statistically significant yet modest effects on intent and use of PE. Changes in beliefs during case consultation had substantial effects on intent and actual use of PE. Pre-training factors and changes in beliefs during training (especially during case consultation) influence clinicians' adoption of PE. Use of PE was influenced not only by its perceived clinical advantages/disadvantages, but also by contextual factors (working in a PTSD specialty clinic, perceived control over one's schedule, and ability to promote PE to patients and colleagues).

Developing an Emotion- and Memory-Processing Group Intervention for PTSD with complex features: a group case series with survivors of repeated interpersonal trauma

Individuals who experience repeated interpersonal trauma exposure often present with posttraumatic stress disorder (PTSD) with more complex features. There is currently no consensus regarding whether current evidence-based interventions for PTSD need to be tailored to better account for these complex features. However, one recommended adaptation is to adopt a phase-based or sequenced approach involving three phases, each with a distinct function. This paper describes the development of a 12-session Emotion- and Memory-Processing Group Programme, adapted from Cloitre's Skills Training in Affective and Interpersonal Regulation (STAIR) phase-based treatment protocol. A single case series provided a preliminary examination of the group-based intervention's efficacy for three groups of women with a history of repeated interpersonal trauma and PTSD with complex features (N = 15; age 19-46 years) at The Haven Sexual Assault Referral Centre in London. Results revealed significant reductions in: PTSD, complex features of PTSD, and depression, along with improvements in process measures of maladaptive cognitions and emotion processing. Results from this case series demonstrate that an Emotion- and Memory-Processing Group Programme holds promise for treating individuals with a history of interpersonal trauma in outpatient settings, and provides evidence to warrant the completion of a feasibility trial.

Impediments and catalysts to task-shifting psychotherapeutic interventions for adolescents with PTSD: perspectives of multi-stakeholders

BACKGROUND

This qualitative study was nested within a randomized controlled trial (RCT) where two psychotherapeutic interventions (supportive counselling and prolonged exposure for adolescents) were provided by supervised nurses (who served as 'nurse counsellors') to adolescents with PTSD in school settings. This paper describes the perspectives of nurse counsellors (NCs) and school liaisons (SLs). SLs were teachers or administrative personnel at the schools who coordinated the study visits of participants with the NCs. We focus on the impediments and catalysts to and recommendations for treatment implementation.

METHODS

NCs (n = 3) and SLs (n = 3) who participated in the RCT during 2014 were purposively recruited by telephone and participated in face-to-face semi-structured in-depth interviews that were recorded and doubly transcribed. Thematic content analysis was applied using Atlas.ti software to identify emerging themes. This paper describes the impediments and catalysts to provide psychotherapy by task-shifting in a community setting across three sub-themes: personal, community, and collaborative care.

RESULTS

Although nurses were initially resistant to supervision it was central to personally coping with complex interventions, managing traumatic content, and working apart from a multi-disciplinary team. Delivering the interventions in the community presented multiple logistical impediments (e.g. transport, communication, venue suitability) which required creative solutions. In light of resource shortages, networking is central to effective delivery and uptake of the interventions. Collaboration between government departments of health and education may have a major impact on providing school-based psychotherapy through task-shifting.

CONCLUSIONS

Impediments to implementation are not insurmountable. This article provides recommendations to maximize the success of task-shifting interventions should they be rolled out.

Feasibility of Training Frontline Therapists in Prolonged Exposure: A Randomized Controlled Pilot Study of Treatment of Complex Trauma in Diverse Victims of Crime and Violence

The study aims were to determine whether prolonged exposure (PE) improved mental health and was feasible to implement by frontline clinicians in a culturally diverse sample with complex trauma. Seventy-one individuals were randomly assigned to PE or person-centered therapy (PCT). Outcome measures were administered at baseline and sessions 3, 6, 9, and 12. Mixed modeling was used to regress outcome measures on time, treatment group, and number of visits. Individuals who received PE showed significant moderate association with decline in reported posttraumatic stress disorder (PTSD) symptoms as noted by the PTSD Checklist for DSM-5 (p = 0.05) compared with PCT. Results indicated improved scores on all measures at each follow-up time point compared with baseline (p ≤ 0.01). PE was feasible, shown by positive recruitment and ability of clinicians to effectively implement and maintain treatment fidelity. Findings suggest that PE can be effective for treating complex trauma when used by clinicians in community settings.

Clinicians' Perception of Patient Readiness for Treatment: An Emerging Theme in Implementation Science?

Despite a training program to help veterans administration (VA) clinicians implement evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), uptake has been limited. To understand clinicians' implementation challenges, we performed thematic analysis of semi-structured telephone interviews guided by the Promoting Action on Research Implementation in Health Services framework. Our sample included 22 psychotherapists in VA PTSD clinics in one region. We identified a theme not captured by our implementation framework: clinicians' perceptions about their patients' readiness for treatment. Clinician perception of patient readiness may be important to the uptake of EBPs and should be considered in mental health implementation work.

PATTERNS OF CHANGE IN RESPONSE TO PROLONGED EXPOSURE: IMPLICATIONS FOR TREATMENT OUTCOME

BACKGROUND

Assessment of response to Prolonged Exposure (PE) suggests some patients may experience discontinuous change involving sudden symptom reductions and/or temporary exacerbations. The current study looked to (1) isolate profiles of PE response among treatment-seeking veterans and (2) identify factors associated with unique patterns of change.

METHODS

Archival records were examined for veterans receiving PE through a specialty Veterans Affairs Medical Center (VAMC) clinic (N = 109). Latent profile analysis was used to extract response trajectories defined by change in weekly PTSD Checklist (PCL) scores. Associations with provider status (staff vs. intern), setting (in-person vs. telehealth), initial severity (PTSD; depression), and eventual treatment gains were examined.

RESULTS

Three profiles were observed. Rapid Responders (18.3%) evidenced sharp reductions at Week 2 and again between Weeks 5 and 6. Linear Responders (40.4%) demonstrated gradual reductions throughout the 10-week assessment window. Delayed Responder (41.3%) scores were relatively stable over the evaluation period although final session outcomes indicated reliable change (PCLΔ > 10) in 40% of patients. Profiles were similar with respect to provider status, treatment setting, and initial symptom severity. Rapid Responders evidenced lower final session scores relative to Linear (g = 1.13) and Delayed (g = 1.85) groups, with Linear Responders reporting lower end scores than Delayed Responders (g = 1.02).

CONCLUSIONS

Anticipating patterns of recovery and their association with therapeutic outcome is of immense clinical value. Sudden gains emerged as a strong predictor of enhanced response. Data also suggest potential benefits of extending standard intervention for patients who fail to demonstrate an immediate response to PE.

Dropout rates in exposure with response prevention for obsessive-compulsive disorder: What do the data really say?

The purposes of this review were to: 1) determine the attrition rates for exposure with response prevention (ERP) for obsessive-compulsive disorder (OCD), 2) compare them to those in other treatments for OCD, and 3) identify predictors of ERP attrition. A systematic literature search of randomized controlled trials for ERP for OCD yielded 21 studies, representing 1400 participants. Attrition data were extracted for individual treatment conditions. The weighted mean dropout rate for ERP was 14.7% (95% CI [11.4%, 18.4%]). This figure was not statistically different from that of comparison conditions (e.g., cognitive therapy; OR=0.67-2.22, all ps>0.15). Only two studies reported refusal rates for ERP (weighted mean=4.0%; 95% CI [0.7%, 9.2%]), which precluded calculation of a reliable refusal rate for ERP. Based on these figures, we estimated an overall attrition rate of 18.7% for ERP. Treatment experience, therapist qualification, and number of treatment sessions did not significantly predict dropout rate. Our review indicates that ERP may have treatment dropout rates similar to other treatments for OCD.

Symptom exacerbations in trauma-focused treatments: Associations with treatment outcome and non-completion

Trauma-focused treatments are underutilized, partially due to clinician concerns that they will cause symptom exacerbation or dropout. We examined a sample of women undergoing Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and a version of CPT (CPT-C) without a written trauma narrative to investigate the possibility of symptom exacerbation. Participants (n = 192) were drawn from two RCT's. Participants were administered self-report measures of PTSD symptoms (i.e., the PTSD Symptom Scale or Posttraumatic Diagnostic Scale [PSS/PDS]) and the Clinician-Administered PTSD Scale. Exacerbations were defined as increases greater than 6.15 points on the PSS/PDS. A minority of participants experienced PTSD exacerbations during treatment, and there were no significant differences across treatment type (28.6% in CPT, 20.0% in PE, and 14.7% in CPT-C). Neither diagnostic nor trauma-related factors at pre-treatment predicted symptom exacerbations. Those who experienced exacerbations had higher post-treatment PSS/PDS scores and were more likely to retain a PTSD diagnosis (both small but statistically significant effects). However, even those who experienced an exacerbation experienced clinically significant improvement by end of treatment. Further, symptom exacerbations were not related to treatment non-completion. These results indicate that trauma-focused treatments are safe and effective, even for the minority of individuals who experience temporary symptom increases.

An Affective Cognitive Neuroscience-Based Approach to PTSD Psychotherapy: The TARGET Model

Adaptations or alternative versions of cognitive psychotherapy for posttraumatic stress disorder (PTSD) are needed because even the most efficacious cognitive or cognitive-behavioral psychotherapies for PTSD do not retain or achieve sustained clinically significant benefits for a majority of recipients. Cognitive affective neuroscience research is reviewed which suggests that it is not just memory (or memories) of traumatic events and related core beliefs about self, the world, and relationships that are altered in PTSD but also memory (and affective information) processing A cognitive psychotherapy is described that was designed to systematically make explicit these otherwise implicit trauma-related alterations in cognitive emotion regulation and its application to the treatment of complex variants of PTSD-Trauma Affect Regulation: Guide for Education and Therapy (TARGET). TARGET provides therapists and clients with (a) a neurobiologically informed strengths-based meta-model of stress-related cognitive processing in the brain and how this is altered by PTSD and (b) a practical algorithm for restoring the executive functions that are necessary to make implicit trauma-related cognitions explicit (i.e., experiential awareness) and modifiable (i.e., planful refocusing). Results of randomized clinical trial studies and quasi-experimental effectiveness evaluations of TARGET with adolescents and adults are reviewed.

Perceived Characteristics of Intervention Scale

The Perceived Characteristics of Intervention Scale (PCIS), a 20-item assessment measure, was developed to assess health care providers’ views of interventions. Two hundred and fifteen Department of Veterans Affairs’ residential treatment providers from 38 programs across the United States completed an online survey that included the PCIS as well as self-reported use of two evidence-based treatments. The PCIS was anchored to ask about two evidence-based psychotherapies for posttraumatic stress disorder, prolonged exposure, and cognitive processing therapy. The PCIS is a reliable measure of perceived characteristics of interventions, with some preliminary support for its validity. Consideration of providers’ perceptions of particular evidence-based treatments may serve as an aid to improve their dissemination, implementation, and sustained use.

PTSD symptom severity and psychiatric comorbidity in recent motor vehicle accident victims: a latent class analysis

We conducted a latent class analysis (LCA) on 249 recent motor vehicle accident (MVA) victims to examine subgroups that differed in posttraumatic stress disorder (PTSD) symptom severity, current major depressive disorder and alcohol/other drug use disorders (MDD/AoDs), gender, and interpersonal trauma history 6-weeks post-MVA. A 4-class model best fit the data with a resilient class displaying asymptomatic PTSD symptom levels/low levels of comorbid disorders; a mild psychopathology class displaying mild PTSD symptom severity and current MDD; a moderate psychopathology class displaying severe PTSD symptom severity and current MDD/AoDs; and a severe psychopathology class displaying extreme PTSD symptom severity and current MDD. Classes also differed with respect to gender composition and history of interpersonal trauma experience. These findings may aid in the development of targeted interventions for recent MVA victims through the identification of subgroups distinguished by different patterns of psychiatric problems experienced 6-weeks post-MVA.

Inclusion and exclusion criteria in randomized controlled trials of psychotherapy for PTSD

OBJECTIVE

Posttraumatic stress disorder (PTSD) is a prevalent and often disabling condition. Fortunately, effective psychological treatments for PTSD are available. However, research indicates that these treatments may be underutilized in clinical practice. One reason for this underutilization may be clinicians' unwarranted exclusion of patients from these treatments based on their understanding of exclusion criteria used in clinical trials of psychological treatments for PTSD. There is no comprehensive and up-to-date review of inclusion and exclusion criteria used in randomized clinical trials (RCTs) of psychological treatments for PTSD. Therefore, our objective was to better understand how patients were excluded from such RCTs in order to provide guidance to clinicians regarding clinical populations likely to benefit from these treatments.

METHODS

We conducted a comprehensive literature review of RCTs of psychological treatments for PTSD from January 1, 1980 through April 1, 2012. We categorized these clinical trials according to the types of psychotherapy discussed in the major guidelines for treatment of PTSD and reviewed all treatments that were studied in at least two RCTs (N=64 published studies with 75 intervention arms since some studies compared two or more interventions). We abstracted and tabulated information concerning exclusion criteria for each type of psychotherapy for PTSD.

RESULTS

We identified multiple RCTs of cognitive behavioral therapy (n=56), eye movement desensitization and reprocessing (n=11), and group psychotherapy (n=8) for PTSD. The most common exclusions were psychosis, substance abuse and dependence, bipolar disorder, and suicidal ideation. Clinical trials varied in how stringently these criteria were applied. It is important to note that no exclusion criterion was used in all studies and there was at least one study of each type of therapy that included patients from each of the commonly excluded groups. A paucity of evidence exists concerning the treatment of patients with PTSD and four comorbidities: alcohol and substance abuse or dependence with current use, current psychosis, current mania, and suicidal ideation with current intent.

CONCLUSIONS

Psychological treatments for PTSD have been studied in broad and representative clinical populations. It appears that more liberal use of these treatments regardless of comorbidities is warranted.

Theory-based training strategies for modifying practitioner concerns about exposure therapy

Despite the well-established efficacy of exposure therapy in the treatment of pathological anxiety, many therapists believe this treatment carries an unacceptably high risk for harm, is intolerable for patients, and poses a number of ethical quandaries. These beliefs have been shown to account for two related problems: (a) underutilization of exposure therapy, and (b) overly cautious and suboptimal delivery the treatment, which likely attenuates treatment outcomes. At present, there is little guidance for those who train exposure therapists to address these concerns. This article reviews therapist negative beliefs about exposure therapy and discusses their modification based on findings from social and cognitive psychology pertinent to belief change, including dual-processing in reasoning, the need for cognition and affect, and attitude inoculation. A number of strategies are offered for augmenting training in exposure therapy in order to promote positive beliefs about the treatment. These strategies involve: (a) therapists engaging in simulated exposure therapy exercises and presenting arguments in defense of exposure's safety, tolerability, and ethicality, and (b) training therapists using emotion-based appeals (e.g., case examples) to supplement research findings. Directions for future research on practitioner concerns about exposure therapy are discussed.

Assessing therapist reservations about exposure therapy for anxiety disorders: the Therapist Beliefs about Exposure Scale

Exposure therapy is underutilized in the treatment of pathological anxiety and is often delivered in a suboptimal manner. Negative beliefs about exposure appear common among therapists and may pose a barrier to its dissemination. To permit reliable and valid assessment of such beliefs, we constructed the 21-item Therapist Beliefs about Exposure Scale (TBES) and examined its reliability and validity in three samples of practicing clinicians. The TBES demonstrated a clear single-factor structure, excellent internal consistency (αs=.90-.96), and exceptionally high six-month test-retest reliability (r=.89). Negative beliefs about exposure therapy were associated with therapist demographic characteristics, negative reactions to a series of exposure therapy case vignettes, and the cautious delivery of exposure therapy in the treatment of a hypothetical client with obsessive-compulsive disorder. Lastly, TBES scores decreased markedly following a didactic workshop on exposure therapy. The present findings support the reliability and validity of the TBES.

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.

Mindfulness-Based Stress Reduction for Low-Income, Predominantly African American Women With PTSD and a History of Intimate Partner Violence

In this article, we consider the use of Mindfulness-Based Stress Reduction (MBSR) (Kabat-Zinn, 1991) as a community-based intervention to reduce health disparities for low-income, predominantly African American women with a history of intimate partner violence (IPV) and posttraumatic stress disorder (PTSD). This article presents our rationale for using MBSR as an intervention with this population, the details of its implementation, and a discussion of the feasibility and acceptability of the intervention based on participants' feedback and our observations. We conclude that the use of MBSR programs for low-income, predominantly African American women with PTSD and a history of IPV is both feasible (of initial interest to and completed by most participants) and acceptable (congruent with and relevant to their needs). Replication with larger samples and examination of mechanisms is warranted by these findings.

Coping focus counselling in mental health nursing

The aim of this paper was to describe a newly-developed system of mental health nurse counselling (coping focus counselling (CFC)) for people with serious and complex mental health needs. The system is based on the recovery alliance theory (RAT) of mental health nursing. The paper identifies shortcomings in current practices in psychotherapy and counselling in the exclusive use of techniques from a single approach, for example, cognitive behaviour therapy, client-centred therapy, attachment theory, or Gestalt theory. It also discusses the opposite dangers of the use of many techniques from different approaches, without a clear rationale for their selection. CFC was developed to avoid these practices. It accommodates the selective use of techniques from different approaches. Techniques selected are viewed as deriving their meanings from the theoretical framework into which they are assimilated, namely RAT, and no longer take the same meaning from the theory from which they originated. Central to this integrative process is the use of the concept of coping. Other distinguishing features of CFC are the use of everyday language in using the system and the reaffirmation of the nurse-client relationship within a working alliance as the basis in which the CFC operates.

Cognitive processing therapy versus supportive counseling for acute stress disorder following assault: a randomized pilot trial

The study tested the efficacy and tolerability of cognitive processing therapy (CPT) for survivors of assault with acute stress disorder. Participants (N=30) were randomly allocated to CPT or supportive counseling. Therapy comprised six individual weekly sessions of 90-min duration. Independent diagnostic assessment for PTSD was conducted at posttreatment. Participants completed self-report measures of posttraumatic stress, depression, and negative trauma-related beliefs at pre-, posttreatment, and 6-month follow-up. Results indicated that both interventions were successful in reducing symptoms at posttreatment with no statistical difference between the two; within and between-group effect sizes and the proportion of participants not meeting PTSD criteria was greater in CPT. Treatment gains were maintained for both groups at 6-month follow-up.

A self-administered, mild form of exposure therapy for older adults

Despite the effectiveness of exposure therapy to alleviate trauma-related distress, many older adults are unable or unwilling to enter therapy. Mild forms of exposure therapy, such as completing memory questionnaires about a stressful event, have been shown to reduce distress in younger adults. This study attempted to examine the impact of a mild form of exposure therapy in an older adult population. A community-living sample of 263 older adults nominated a stressful event from their lives, and were randomly assigned to either complete questionnaires concerning their memory of the stressful event, or a control task. Results indicated that those who had completed the memory questionnaires about a nominated stressful event evidenced lower levels of distress two weeks later. This effect was stronger for events that were either more recent or had elevated initial levels of distress. These findings suggest an alternative treatment for older adults who have experienced a stressful or traumatic event.

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.

Prolonged exposure for the treatment of Spanish-speaking Puerto Ricans with posttraumatic stress disorder: a feasibility study

BACKGROUND

Most of the empirical studies that support the efficacy of prolonged exposure (PE) for treating posttraumatic stress disorder (PTSD) have been conducted on white mainstream English-speaking populations. Although high PTSD rates have been reported for Puerto Ricans, the appropriateness of PE for this population remains unclear. The purpose of this study was to examine the feasibility of providing PE to Spanish speaking Puerto Ricans with PTSD. Particular attention was also focused on identifying challenges faced by clinicians with limited experience in PE. This information is relevant to help inform practice implications for training Spanish-speaking clinicians in PE.

RESULTS

Fourteen patients with PTSD were randomly assigned to receive PE (n = 7) or usual care (UC) (n = 7). PE therapy consisted of 15 weekly sessions focused on gradually confronting and emotionally processing distressing trauma-related memories and reminders. Five patients completed PE treatment; all patients attended the 15 sessions available to them. In UC, patients received mental health services available within the health care setting where they were recruited. They also had the option of self-referring to a mental health provider outside the study setting. The Clinician-Administered PTSD Scale (CAPS) was administered at baseline, mid-treatment, and post-treatment to assess PTSD symptom severity. Treatment completers in the PE group demonstrated significantly greater reductions in PTSD symptoms than the UC group. Forty percent of the PE patients showed clinically meaningful reductions in PTSD symptoms from pre- to post-treatment.

CONCLUSIONS

PE appears to be viable for treating Puerto Rican Spanish-speaking patients with PTSD. This therapy had good patient acceptability and led to improvements in PTSD symptoms. Attention to the clinicians' training process contributed strongly to helping them overcome the challenges posed by the intervention and increased their acceptance of PE.

Trauma exposure and posttraumatic stress disorder in adults with severe mental illness: a critical review

There is a great deal of research on the prevalence, correlates, and treatment of PTSD in the general population. However, we know very little about the manifestation and consequences of PTSD in more complicated patient populations. The purpose of the current paper is to provide a comprehensive review of PTSD within the context of severe mental illness (SMI; i.e., schizophrenia spectrum disorders, mood disorders). Extant data suggest that trauma and PTSD are highly prevalent among individuals with SMI relative to the general population, and both are associated with adverse clinical functioning and increased healthcare burden. However, trauma and PTSD remain overlooked in this population, with low recognition rates in public-sector settings. Additionally, there are few data on the clinical course and treatment of PTSD among individuals with SMI. Particularly lacking are longitudinal studies, randomized controlled treatment trials, and studies using ethno-racially diverse samples. Furthermore, there is a need to better understand the interplay between trauma, PTSD, and severe forms of mental illness and to further develop and disseminate evidence-based PTSD treatments in this population. The current state of the literature and future directions for practice are discussed.

Multicomponent behavioral treatment for chronic combat-related posttraumatic stress disorder: a randomized controlled trial

This study examined the efficacy of a multicomponent cognitive-behavioral therapy, Trauma Management Therapy, which combines exposure therapy and social emotional rehabilitation, to exposure therapy only in a group of male combat veterans with chronic posttraumatic stress disorder (PTSD). Thirty-five male Vietnam veterans with PTSD were randomly assigned to receive either Trauma Management Therapy (TMT) or Exposure Therapy Only (EXP). Participants were assessed at pre-treatment, mid-treatment, and post-treatment. Primary clinical outcomes were reduction of PTSD symptoms and improved social emotional functioning. Results indicated that veterans in both conditions showed statistically significant and clinically meaningful reductions in PTSD symptoms from pre- to post-treatment, though consistent with a priori hypotheses there were no group differences on PTSD variables. However, compared to the EXP group, participants in the TMT group showed increased frequency in social activities and greater time spent in social activities. These changes occurred from mid-treatment (after completion of exposure therapy) to post-treatment (after completion of the social emotional rehabilitation component); supporting the hypothesis that TMT alone would result in improved social functioning. Although the TMT group also had a significant decrease in episodes of physical rage, that change occurred prior to introduction of the social emotional component of TMT. This study demonstrates efficacy of exposure therapy for treating the core symptoms of PTSD among combat veterans with a severe and chronic form of this disorder. Moreover, multi-component CBT shows promise for improving social functioning beyond that provided by exposure therapy alone, particularly by increasing social engagement/interpersonal functioning in a cohort of veterans with severe and chronic PTSD.

Prolonged exposure versus dynamic therapy for adolescent PTSD: a pilot randomized controlled trial

OBJECTIVE

To examine the efficacy and maintenance of developmentally adapted prolonged exposure therapy for adolescents (PE-A) compared with active control time-limited dynamic therapy (TLDP-A) for decreasing posttraumatic and depressive symptoms in adolescent victims of single-event traumas.

METHOD

Thirty-eight adolescents (12 to 18 years old) were randomly assigned to receive PE-A or TLDP-A.

RESULTS

Both treatments resulted in decreased posttraumatic stress disorder and depression and increased functioning. PE-A exhibited a greater decrease of posttraumatic stress disorder and depression symptom severity and a greater increase in global functioning than did TDLP-A. After treatment, 68.4% of adolescents beginning treatment with PE-A and 36.8% of those beginning treatment with TLDP-A no longer met diagnostic criteria for posttraumatic stress disorder. Treatment gains were maintained at 6- and 17-month follow-ups.

CONCLUSIONS

Brief individual therapy is effective in decreasing posttraumatic distress and behavioral trauma-focused components enhance efficacy. CLINICAL TRIAL REGISTRY INFORMATION: Prolonged Exposure Therapy Versus Active Psychotherapy in Treating Post-Traumatic Stress Disorder in Adolescents, URL: http://clinicaltrials.gov, unique identifier: NCT00183690.

When do trauma experts choose exposure therapy for PTSD patients? A controlled study of therapist and patient factors

To investigate when and why therapists opt for or rule out imaginal exposure (IE) for patients with posttraumatic stress disorder (PTSD), 255 trauma experts were randomized to two conditions in which they were presented with four cases in which the patients' comorbidity and treatment preferences were manipulated. The results confirmed IE to be an underutilized approach, with the majority of professionals being undertrained in the technique. As predicted, the patient factors influenced the expert's choice of therapy: in case of a comorbid depression, IE was significantly less preferred than medication. Also, IE was significantly more likely to be offered when patients expressed a preference for trauma-focused treatment. The therapist factors were also found to be importantly related to treatment preferences, with high credibility in the technique being positively related to the therapists' preference for IE. Perceived barriers to IE, such as a fear of symptom exacerbation and dropout, were negatively related to the perceived suitability of the treatment when patients had suffered multiple traumas in childhood. The results are discussed in the light of clinical implications and the need of exposure training for trauma professionals.

Rape treatment outcome research: empirical findings and state of the literature

This article reviews empirical support for treatments targeting women sexually assaulted during adolescence or adulthood. Thirty-two articles were located using data from 20 separate samples. Of the 20 samples, 12 targeted victims with chronic symptoms, three focused on the acute period post-assault, two included women with chronic and acute symptoms, and three were secondary prevention programs. The majority of studies focus on posttraumatic stress disorder (PTSD), depression, and/or anxiety as treatment targets. Cognitive Processing Therapy and Prolonged Exposure have garnered the most support with this population. Stress Inoculation Training and Eye Movement Desensitization and Reprocessing also show some efficacy. Of the four studies that compared active treatments, few differences were found. Overall, cognitive behavioral interventions lead to better PTSD outcomes than supportive counseling does. However, even in the strongest treatments more than one-third of women retain a PTSD diagnosis at post-treatment or drop out of treatment. Discussion highlights the paucity of research in this area, methodological limitations of examined studies, generalizability of findings, and important directions for future research at various stages of trauma recovery.

Exposure-based cognitive-behavioral treatment of PTSD in adults with schizophrenia or schizoaffective disorder: a pilot study

In an open trial design, adults (n=20) with posttraumatic stress disorder (PTSD) and either schizophrenia or schizoaffective disorder were treated via an 11-week cognitive-behavioral intervention for PTSD that consisted of education, anxiety management therapy, social skills training, and exposure therapy, provided at community mental health centers. Results offer preliminary hope for effective treatment of PTSD among adults with schizophrenia or schizoaffective disorder, especially among treatment completers (n=13). Data showed significant PTSD symptom improvement, maintained at 3-month follow-up. Further, 12 of 13 completers no longer met criteria for PTSD or were considered treatment responders. Clinical outcomes for other targeted domains (e.g., anger, general mental health) also improved and were maintained at 3-month follow-up. Participants evidenced high treatment satisfaction, with no adverse events. Significant improvements were not noted on depression, general anxiety, or physical health status. Future directions include the need for randomized controlled trials and dissemination efforts.