Outcomes of Trauma Treatment Using the TARGET Model

Commentary: Improving the Effectiveness and Utility of the Helping to End Addiction Long-Term (HEAL) Prevention Cooperative: A Full Translational Framework

The Helping to End Addiction Long-term (HEAL) Prevention Collaborative (HPC) is designed to expedite the development of programs aimed at preventing opioid misuse and opioid use disorder (OUD) in older adolescents and young adults (ages 16-30). Funded by the National Institutes of Health Office of the Director (ODP-NIH), the HPC includes ten outcome studies that focus on distinct interventions to determine their effectiveness and real-world applicability. Also included is a coordinating center at RTI International that supports the individual projects. This commentary highlights the scientific and practical significance of this cooperative and its promise for facilitating the production and implementation of successful interventions. Attributes such as novel program designs, advanced methodologies, addressing unique characteristics of diverse populations, and real-time analysis of data and costs make this cooperative highly innovative. We note, however, that papers in this Supplemental Issue did not specifically address the persistent need to obtain stronger effect sizes than those achieved to date. Existing data captured earlier in development (< 16 years of age) are uncovering interactive neurocognitive and social-contextual mechanisms underlying the phenomena we wish to prevent. HPC projects could be guided by this information to incorporate developmentally appropriate measures of mechanisms shown previously to be influential in targeted outcomes and determine how they are impacted by specific components of their interventions. This mechanistic information can provide a roadmap for constructing interventions that are more precision-based and, thus, more likely to yield greater benefits for a larger number of recipients. Furthermore, an understanding of underlying mechanism(s) promises to shed light on the sources of heterogeneity in outcomes for further intervention refinement. It is quite possible, if not probable, that meaningful measures of underlying processes will reveal subtypes-some with very high effect sizes and others that are much lower-directly enabling program refinements to more directly target mechanisms that portend and explain less favorable outcomes. Described herein is a full-spectrum translational approach which promises to significantly boost effect sizes, a key objective that should be reached prior to scaling.

Project Harmony: A Meta-Analysis With Individual Patient Data on Behavioral and Pharmacologic Trials for Comorbid Posttraumatic Stress and Alcohol or Other Drug Use Disorders

OBJECTIVE

Treatment efficacy for co-occurring posttraumatic stress disorder (PTSD) and substance use disorders is well established, yet direct evidence for comparative effectiveness across treatments is lacking. The present study compared the effectiveness of several behavioral and pharmacological therapies for adults with co-occurring PTSD and alcohol or other drug use disorders.

METHODS

A systematic search of PsycINFO, MEDLINE, and ClinicalTrials.gov was conducted through December 2020 for trials targeting PTSD, alcohol or other drug use disorders, or both disorders (36 studies, N=4,046). Primary outcomes were severity scores for PTSD, alcohol use, and drug use, estimated via moderated nonlinear factor analysis. Propensity score weight-adjusted multilevel models were used. Model-predicted effect sizes were estimated for each treatment, and comparative effect sizes for each active arm against treatment as usual, at end of treatment and at 12-month follow-up.

RESULTS

Compared with treatment as usual, combining trauma-focused therapy and pharmacotherapy for substance use disorders showed the largest comparative effect sizes for PTSD severity (d=-0.92, 95% CI=-1.57, -0.30) and alcohol use severity (d=-1.10, 95% CI=-1.54, -0.68) at end of treatment. Other treatments with large comparative effect sizes included pharmacotherapies for alcohol or other drug use disorders, trauma-focused integrated therapies, and trauma-focused nonintegrated therapies. Reductions in outcomes for PTSD symptoms and alcohol use were observed for nearly all treatments.

CONCLUSIONS

The findings provide support for treating comorbid PTSD and substance use disorders using a variety of approaches, with alcohol-targeted pharmacotherapies and trauma-focused behavioral therapies as a combination of treatments that lead to early and sustained improvements in PTSD and alcohol use severity. Further treatment development is indicated for combining behavioral and pharmacological treatments for synergized impact and understanding the mechanisms of action and conditions under which each treatment type is optimized.

Group therapy in primary care settings for the treatment of posttraumatic stress disorder: A systematic literature review

OBJECTIVE

This systematic review aims to summarize existing literature on group therapy for the treatment of post-traumatic stress disorder (PTSD) in primary care.

METHOD

A PRISMA systematic literature review was performed through February 26, 2022 identifying existing studies of group trauma therapy in primary care. Articles were included if they discussed group trauma therapy for primary care patients. Bias was assessed based on sample sizes and presence of control groups. Results are presented as a weighted average of the engagement rate and a qualitative description of overlapping study traits.

RESULTS

Four studies of group PTSD treatment within primary care were identified with 70 total patients completing group treatment. The weighted treatment engagement rate was 65%. Each utilized distinct group trauma treatment models and reported significant patient improvements in PTSD symptoms on standardized trauma symptom scales.

DISCUSSION

Group trauma therapy models are available and can be disseminated within primary care settings. Limitations include both the small number of studies and participants.

CONCLUSION

There have been few studies of group therapy for PTSD in primary care, but these could represent a promising and scalable approach to meet the high need for trauma treatment. Further research is needed regarding implementation feasibility and impact.

A systematic review and meta-analysis of psychological interventions for comorbid post-traumatic stress disorder and substance use disorder

Background

The psychological treatment of comorbid post-traumatic stress disorder (PTSD) and substance use disorder (SUD) is clinically challenging, and outcomes are often poor.

Objective

This paper describes a systematic review and meta-analysis which sought to establish the current efficacy for a number of established psychological approaches for adults and adolescents, in comparison to interventions for SUD alone, or other active approaches, following a pre-registered protocol.

Method

This review followed PRISMA and Cochrane Collaboration guidelines. Data extraction and risk of bias judgements using Cochrane criteria were undertaken by all authors. Primary outcomes were PTSD severity and substance use post-treatment. The quality of findings was assessed using GRADE. Following a comprehensive search, conducted to 13 September 2021, 27 studies were included.

Results

We found a relatively high level of dropout across studies. In our main comparisons, we found no benefits for present-focused treatment approaches aimed at improving coping skills beyond those for SUD-only interventions. We found modest benefits for trauma-focused intervention plus SUD intervention post-treatment for PTSD (standardized mean difference (SMD) = -0.36, 95% confidence interval (CI) -0.64, -0.08), and at 6-13 months for PTSD (SMD = -0.48, 95% CI -0.81, -0.15) and alcohol use (SMD = -0.23, 95% CI -0.44, -0.02). There were no benefits for cognitive restructuring interventions as a group, but we found a modest effect for integrated cognitive behavioural therapy (ICBT) for PTSD post-treatment (SMD = -0.33, 95% CI -0.62, -0.04). There was evidence of some benefit for trauma-focused intervention over present-focused intervention for PTSD from a single study and for reduction in dropout for incentivized attendance for trauma-focused intervention from another single study. Most findings were of very low quality.

Conclusion

There is evidence that trauma-focused therapy and ICBT can improve PTSD for some individuals, but many patients do not fully engage with treatment and average treatment effects are modest.

HIGHLIGHTS

For PTSD, evidence was strongest for trauma-focused CBT-based approaches, but effects were modest.There was little evidence of any added benefit on substance use, beyond that of standard addiction treatments, for any included intervention.Dropout from treatment was high.

Improved emotion regulation following a trauma-informed CBT-based intervention associates with reduced risk for recidivism in justice-involved emerging adults

OBJECTIVE

Male youth who have been involved in the juvenile legal system have disproportionate rates of trauma and violence exposure. Many justice-involved youth have untreated mental illness, with an estimated 66% of young men who are incarcerated meeting criteria for at least one mental health disorder, including posttraumatic stress disorder (PTSD), depression, and substance abuse. While Cognitive Behavioral Therapy (CBT) approaches are considered among effective evidence-based treatments for addressing and treating behavioral and emotional difficulties, male youth with a history of incarceration and youth who are at risk for (re)incarceration, violence, emotion dysregulation, and trauma face significant barriers in accessing these services.

METHODS

Roca, Inc. (Roca), an internationally recognized organization moving the needle on urban violence by working relentlessly with young people at the center of violence in Massachusetts and Maryland, employs a trauma-informed CBT-based skills curriculum and approach in their intervention model, to improve youths' educational, employment, parenting, and life skills opportunities, while decreasing risk for recidivism, addressing trauma and increasing skills for emotion regulation. The aim of this analysis was to assess the effectiveness of Roca's trauma-informed CBT skills curriculum on youths' emotional and behavioral outcomes. We analyzed data from over 300 participating emerging adult men from four sites in Massachusetts and one site in Baltimore, Maryland who had at least three series of data collection across multiple skills-based sessions.

RESULTS

We found improvements in outcomes in overall mean scores related to decreased distress about employment and education, as are expected with standard intervention approaches for justice-involved youth. Participants who show improvement in emotion regulation across engagement (approximately half the cohort), were found to have significant improvements in distress related to relationship and family functioning and self-care, and decreased substance use, along with other outcomes compared to those participants with less improvement in emotion regulation. Furthermore, improvement in different aspects of emotion regulation were associated with improved relationships, life distress, substance use, and improved prosocial thinking.

CONCLUSIONS

Together, these data suggest that adding mental health support and skills training, such as with trauma-informed CBT models, to programs for justice-involved youth may lead to significant improvements in functioning, quality of life, and mental health outcomes.

Efficacy and acceptability of interventions for co-occurring PTSD and SUD: A meta-analysis

Over the past 20 years, numerous treatments addressing comorbid Posttraumatic Stress Disorder (PTSD) and Substance Use Disorder (SUD) have been developed and tested. The current meta-analysis examined the efficacy and acceptability of the two central treatment types- trauma-focused and non-trauma-focused - compared with all comparators and with cognitive-behavioral manualized SUD treatments immediately post-treatment and at longest follow-up. Twenty-eight randomized clinical trials (N = 3247) were included. There were small to large within-group effects for all forms of active treatment (gs = 0.30-1.11). Trauma-focused but not non-trauma-focused treatments outperformed all comparators on PTSD outcomes at post-treatment. Neither trauma-focused nor non-trauma-focused treatment outperformed all comparators on SUD outcomes at post-treatment. Neither trauma- nor non-trauma-focused treatment outperformed manualized SUD treatments on PTSD outcomes at either time point. Manualized SUD treatments outperformed trauma-focused treatments on SUD outcomes at post-treatment and non-trauma-focused treatments on PTSD outcomes at follow-up. Regarding treatment retention, neither trauma-focused nor non-trauma-focused treatments significantly differed from all comparators or from manualized SUD treatments. Between-group results were largely unchanged in trim-and-fill analyses, but were not robust to fail-safe N. Few moderators were detected. Taken together, results suggest that trauma-focused, non-trauma-focused, and manualized SUD interventions are sound options for individuals with comorbid PTSD/SUD.

Trauma informed interventions: A systematic review

BACKGROUND

Health inequities remain a public health concern. Chronic adversity such as discrimination or racism as trauma may perpetuate health inequities in marginalized populations. There is a growing body of the literature on trauma informed and culturally competent care as essential elements of promoting health equity, yet no prior review has systematically addressed trauma informed interventions. The purpose of this study was to appraise the types, setting, scope, and delivery of trauma informed interventions and associated outcomes.

METHODS

We performed database searches- PubMed, Embase, CINAHL, SCOPUS and PsycINFO-to identify quantitative studies published in English before June 2019. Thirty-two unique studies with one companion article met the eligibility criteria.

RESULTS

More than half of the 32 studies were randomized controlled trials (n = 19). Thirteen studies were conducted in the United States. Child abuse, domestic violence, or sexual assault were the most common types of trauma addressed (n = 16). While the interventions were largely focused on reducing symptoms of post-traumatic stress disorder (PTSD) (n = 23), depression (n = 16), or anxiety (n = 10), trauma informed interventions were mostly delivered in an outpatient setting (n = 20) by medical professionals (n = 21). Two most frequently used interventions were eye movement desensitization and reprocessing (n = 6) and cognitive behavioral therapy (n = 5). Intervention fidelity was addressed in 16 studies. Trauma informed interventions significantly reduced PTSD symptoms in 11 of 23 studies. Fifteen studies found improvements in three main psychological outcomes including PTSD symptoms (11 of 23), depression (9 of 16), and anxiety (5 of 10). Cognitive behavioral therapy consistently improved a wide range of outcomes including depression, anxiety, emotional dysregulation, interpersonal problems, and risky behaviors (n = 5).

CONCLUSIONS

There is inconsistent evidence to support trauma informed interventions as an effective approach for psychological outcomes. Future trauma informed intervention should be expanded in scope to address a wide range of trauma types such as racism and discrimination. Additionally, a wider range of trauma outcomes should be studied.

Gender Differences in Complex Posttraumatic Stress Symptoms, and Their Relationship to Mental Health and Substance Abuse Outcomes in Incarcerated Adults

Complex trauma (CT; for example, childhood abuse) has been associated with significant behavioral health problems (i.e., mental health and substance use disorders) and symptoms that are consistent with complex posttraumatic stress disorder (C-PTSD). CT is prevalent in adult forensic populations, and particularly important for women as they tend to report more adverse consequences of exposure to traumatic stressors and are entering the criminal justice system at a heightened rate compared with men. However, no studies have empirically tested the relationship among CT, C-PTSD, and behavioral health problems with gender among incarcerated adults. The present study examined the relationship between gender and childhood abuse history, C-PTSD symptom severity, and behavioral health problems in 497 incarcerated adults. Findings indicate that women were more likely to report a history of childhood abuse, and more severe C-PTSD symptoms and behavioral health problems than men. Childhood abuse history significantly accounted for the gender difference observed in C-PTSD symptom severity. C-PTSD partially mediated the gender difference in psychiatric morbidity and in risk of hard drug use. Implications for trauma-informed and gender-responsive services and research in the adult criminal justice system are discussed.

Interpersonal Violence Exposure and Chronic Pain in Adult Sickle Cell Patients

Almost half of sickle cell disease (SCD) patients develop chronic, debilitating physical pain with uncertain genesis for which they primarily receive opiate-based palliative treatment. Psychological trauma exposure, especially interpersonal victimization, has been linked to the perception of pain in several medical diseases, but has yet to be examined in SCD patients. This study examines self-reported chronicity of pain and use of prescribed opiates in 50 adult SCD patients with and without a history of interpersonal violence exposure. We conducted a retrospective chart review of 50 consecutive SCD patients seen for medical care in an adult subspecialty hematology clinic. Data collected included demographics, opiate use, pain chronicity, and measures of anxiety, depression, and interpersonal violence exposure. Sixty-eight percent of patients reported past interpersonal violence exposure. The mean number of types of interpersonal violence exposure, including physical, sexual, or emotional abuse, was 2.76 (SD = 1.63). SCD patients with a history of interpersonal violence exposure were almost five times more likely to report chronic pain and more than six times more likely to report use of opiate-based medications on a daily basis compared with SCD patients with no history of violence exposure. Depression and anxiety symptoms were associated with violence exposure, but did not account for the relationship between violence exposure and chronic pain or prescribed opiate use. Screening and assessment of exposure to interpersonal violence may be useful in addition to screening for mental health problems in the management of chronic pain with adults diagnosed with SCD. Such screening may contribute to addressing health care disparities given the preponderance of SCD patients who are of African American ethnoracial background.

Más allá de las barreras: Competency and practice considerations in language, cultural, and social issues when delivering group CPT to Hispanic immigrants

High rates of under-assessed trauma and psychiatric disorders, particularly posttraumatic stress disorder (PTSD) have been reported among Hispanic immigrants, especially as related to immigration trauma. Multiple studies have shown group cognitive processing therapy (CPT) to be an effective evidence-based practice (EBP) for treatment of PTSD across a number of clinical populations. To date, however, no studies have examined important competency and practice issues in linguistic, cultural, and ethical areas that group CPT providers should consider when delivering group CPT to Hispanic immigrants. This paper aims to outline these and provide future directions for research.

A systematic review of comprehensive interventions for substance abuse: Focus on victimization

Violence victimization is common among men and women who use substances and is associated with co-occurring health issues such as PTSD, depression and HIV. Substance use interventions, therefore, should include integrated components that are designed to address co-occurring health issues among victimized substance-using individuals. This systematic review synthesized the evidence on efficacy of comprehensive, integrated, multicomponent interventions for victimized substance-using individuals. The efficacy of integrated multicomponent intervention strategies was assessed for the following syndemic conditions: mental health, substance misuse, violence, and HIV risk. Seventeen studies were identified. Examples of effective components were empowerment strategies for violence, mindfulness-based stress reduction for mental health, social cognitive skill building for addressing HIV risk and psychoeducation for substance misuse. Although in this review, some components were found to be effective, we identified methodological limitations of included studies which calls for more rigorous research in this area. Further, there is lack of evidence base for multicomponent interventions for victimized substance-using individuals in developing countries. Additional studies are needed to establish rigorous evidence base for multicomponent interventions for victimized substance using individuals that help them cope effectively with their trauma of violence and address their needs.

A systematic review and meta-analysis of group treatments for adults with symptoms associated with complex post-traumatic stress disorder

BACKGROUND

No previous meta-analyses have specifically investigated the effectiveness of psychological group therapy for symptoms associated with complex interpersonal trauma, including whether trauma memory processing (TMP) therapies are superior to psychoeducational approaches alone.

METHODS

A systematic review identified 36 randomised control trials (RCTs) which were included in the meta-analysis.

RESULTS

Large significant effect sizes were evident for TMP interventions when compared to usual care for three outcome domains including: PTSD (k = 6, g = -0.98, 95% CI -1.53, -0.43), Depression (k = 7, g = -1.12, 95% CI -2.01, -0.23) and Psychological Distress (k = 6, g = -0.98, 95% CI 1.66, -0.40). When TMP and psychoeducation interventions were directly compared, results indicated a small non-significant effect in favour of the former for PTSD symptoms, (k = 4, g = -0.34, 95% CI -1.05, 0.36) and small non-significant effect sizes in favour of the latter for Depression (k = 3, g = 0.29, 95% CI -0.83, 1.4) and Psychological Distress (k = 6, g = 0.19, 95% CI -0.34, 0.71).

LIMITATIONS

Heterogeneity and a limited number of high quality RCTs, particularly in the Substance Misuse and Dissociation domains, resulted in uncertainty regarding meta-analytical estimates and subsequent conclusions.

CONCLUSIONS

Results suggest that TMP interventions are useful for traumatic stress whereas non-TMP interventions can be useful for symptoms of general distress (e.g. anxiety and depression). Thus, both TMP and psychoeducation can be useful for the treatment of complex interpersonal trauma symptoms and further research should unravel appropriate sequencing and dose of these interventions.

Effect of Victimization on Impulse Control and Binge Drinking among Serious Juvenile Offenders from Adolescence to Young Adulthood

A vast literature has found longitudinal effects of early life stress on substance use and self-regulatory processes. These associations may vary by period-specific development among youth involved in the juvenile justice system. The current study used an accelerated longitudinal design and auto-regressive latent trajectory with structure residuals (ALT-SR) model to examine the within-person cross-lagged associations between binge drinking, impulse control, and victimization from 15 to 25 years of age. A large sample (N = 1100) of justice-involved youth were followed longitudinally for 7 years (M age baseline  = 15.8, M age conclusion  = 22.8). In general, the sample was ethnically diverse (41% Black, 34% Hispanic, 21% White, 4.3% Other) and primarily male (87.2%). Participants reported on their frequency of binge drinking, impulse control, and frequency of victimization at each time point. The results indicated that, during adolescence, victimization and binge drinking attenuated impulse control, which resulted in more binge drinking and victimization during young adulthood. The current study highlights the importance of assessing developmental processes and period-specific transitions among at risk youth, especially for youth experiencing early life stress.

No Wrong Doors: Findings from a Critical Review of Behavioral Randomized Clinical Trials for Individuals with Co-Occurring Alcohol/Drug Problems and Posttraumatic Stress Disorder

Prior reviews of behavioral treatments for individuals with comorbid alcohol and drug use disorders (substance use disorder SUD) and posttraumatic stress disorder (PTSD) have not systematically considered whether comparison conditions are matched to target treatments on time and attention. A systematic literature search using PubMed MESH terms for alcohol and substance use disorders, PTSD, and treatment identified relevant behavioral randomized clinical trials (RCTs) that evaluated PTSD-oriented exposure-based treatments, addiction-focused treatments, and coping-based treatments that do not involve exposure to trauma memories. Information pertaining to within-subject changes over time and between-subject differences, quality of control condition, recruitment efficiency, and assessment and treatment retention was synthesized. Alcohol and drug outcomes were described separately when possible. Twenty-four behavioral RCTs were identified: 7 exposure based, 6 addiction focused, and 11 coping based. Seven studies included SUD intervention comparison conditions matched to the target intervention on time and attention. Most of the 24 studies found that participants in both the experimental and control conditions improved significantly over time on SUD and PTSD outcomes. No study found significant between-group differences in both SUD and PTSD outcomes favoring the experimental treatment. Despite greater treatment dropout, there was greater improvement in some PTSD outcomes for exposure-based interventions than the control conditions, including when the control conditions were matched for time and attention. Addiction-focused and coping-based interventions did not generally show an advantage over comparably robust controls, although some coping-based interventions yielded better drug use outcomes than control conditions. When available, interventions that integrate exposure-based PTSD treatment and behavioral SUD treatment are recommended as they are associated with better PTSD outcomes than SUD care matched for time and attention. However, the results of this critical review also suggest that people with SUD/PTSD can benefit from a variety of treatment options, including standard SUD care.

Social Ecological Determinants of Substance Use Treatment Entry Among Serious Juvenile Offenders From Adolescence Through Emerging Adulthood

PURPOSE

To examine the social-ecological determinants of substance use treatment entry among serious juvenile offenders over a 7 year period. Using the social-ecological framework, relevant predictors of substance use from the literature were used to assess risk (and protective) factors at the individual, parental, peer and neighborhood level.

METHOD

Serious juvenile offenders (N=1354, M_{age baseline}=16.0 years, SD=1.14) were prospectively followed over 7 years (M_{age Conclusion}=23.0 years, SD=1.15). Cox regression with time invariant and time varying predictors was used to predict time to first substance use treatment entry.

RESULTS

Results for each dimension, separately, varied slightly from the full model. In the full model peer delinquency, peer arrests, post-traumatic stress disorder (PTSD), impulse control, temperament, and emotional regulation remained salient risk (and protective) factors for treatment entry.

CONCLUSION

Associating with more deviant peers and having more of your peers arrested over the 7 year study period was associated with substantial increase in time to treatment entry. Furthermore, one of the strongest risk factors for treatment entry was a PTSD diagnosis. Treatment implications are discussed regarding peer affiliation and PTSD symptomology as well as potential neurological and biological contributors to increased risk for treatment entry.

The Relationship between Interpersonal Violence Victimization and Smoking Behavior across Time and by Gender

The current study examined relationships between interpersonal violence victimization and smoking from childhood to adulthood. Data were from a community-based longitudinal study (N = 808) spanning ages 10 - 33. Cross-lag path analysis was used to model concurrent, directional, and reciprocal effects. Results indicate that childhood physical abuse predicted smoking and partner violence in young adulthood; partner violence and smoking were reciprocally related in the transition from young-adulthood to adulthood. Gender differences in this relationship were not detected. Social work prevention efforts focused on interpersonal violence and interventions targeting smoking cessation may be critical factors for reducing both issues.

Psychological therapies for post-traumatic stress disorder and comorbid substance use disorder

BACKGROUND

Post-traumatic stress disorder (PTSD) is a debilitating mental health disorder that may develop after exposure to traumatic events. Substance use disorder (SUD) is a behavioural disorder in which the use of one or more substances is associated with heightened levels of distress, clinically significant impairment of functioning, or both. PTSD and SUD frequently occur together. The comorbidity is widely recognised as being difficult to treat and is associated with poorer treatment completion and poorer outcomes than for either condition alone. Several psychological therapies have been developed to treat the comorbidity, however there is no consensus about which therapies are most effective.

OBJECTIVES

To determine the efficacy of psychological therapies aimed at treating traumatic stress symptoms, substance misuse symptoms, or both in people with comorbid PTSD and SUD in comparison with control conditions (usual care, waiting-list conditions, and no treatment) and other psychological therapies.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR) all years to 11 March 2015. This register contains relevant randomised controlled trials from the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We also searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov, contacted experts, searched bibliographies of included studies, and performed citation searches of identified articles.

SELECTION CRITERIA

Randomised controlled trials of individual or group psychological therapies delivered to individuals with PTSD and comorbid substance use, compared with waiting-list conditions, usual care, or minimal intervention or to other psychological therapies.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 14 studies with 1506 participants, of which 13 studies were included in the quantitative synthesis. Most studies involved adult populations. Studies were conducted in a variety of settings. We performed four comparisons investigating the effects of psychological therapies with a trauma-focused component and non-trauma-focused interventions against treatment as usual/minimal intervention and other active psychological therapies. Comparisons were stratified for individual- or group-based therapies. All active interventions were based on cognitive behavioural therapy. Our main findings were as follows.Individual-based psychological therapies with a trauma-focused component plus adjunctive SUD intervention was more effective than treatment as usual (TAU)/minimal intervention for PTSD severity post-treatment (standardised mean difference (SMD) -0.41; 95% confidence interval (CI) -0.72 to -0.10; 4 studies; n = 405; very low-quality evidence) and at 3 to 4 and 5 to 7 months' follow-up. There was no evidence of an effect for level of drug/alcohol use post-treatment (SMD -0.13; 95% CI -0.41 to 0.15; 3 studies; n = 388; very low-quality evidence), but there was a small effect in favour of individual psychological therapy at 5 to 7 months (SMD -0.28; 95% CI -0.48 to -0.07; 3 studies; n = 388) when compared against TAU. Fewer participants completed trauma-focused therapy than TAU (risk ratio (RR) 0.78; 95% CI 0.64 to 0.96; 3 studies; n = 316; low-quality evidence).Individual-based psychological therapy with a trauma-focused component did not perform better than psychological therapy for SUD only for PTSD severity (mean difference (MD) -3.91; 95% CI -19.16 to 11.34; 1 study; n = 46; low-quality evidence) or drug/alcohol use (MD -1.27; 95% CI -5.76 to 3.22; 1 study; n = 46; low-quality evidence). Findings were based on one small study. No effects were observed for rates of therapy completion (RR 1.00; 95% CI 0.74 to 1.36; 1 study; n = 62; low-quality evidence).Non-trauma-focused psychological therapies did not perform better than TAU/minimal intervention for PTSD severity when delivered on an individual (SMD -0.22; 95% CI -0.83 to 0.39; 1 study; n = 44; low-quality evidence) or group basis (SMD -0.02; 95% CI -0.19 to 0.16; 4 studies; n = 513; low-quality evidence). There were no data on the effects on drug/alcohol use for individual therapy. There was no evidence of an effect on the level of drug/alcohol use for group-based therapy (SMD -0.03; 95% CI -0.37 to 0.31; 4 studies; n = 414; very low-quality evidence). A post-hoc analysis for full dose of a widely established group therapy called Seeking Safety showed reduced drug/alcohol use post-treatment (SMD -0.67; 95% CI -1.14 to -0.19; 2 studies; n = 111), but not at subsequent follow-ups. Data on the number of participants completing therapy were not for individual-based therapy. No effects were observed for rates of therapy completion for group-based therapy (RR 1.13; 95% CI 0.88 to 1.45; 2 studies; n = 217; low-quality evidence).Non-trauma-focused psychological therapy did not perform better than psychological therapy for SUD only for PTSD severity (SMD -0.26; 95% CI -1.29 to 0.77; 2 studies; n = 128; very low-quality evidence) or drug/alcohol use (SMD 0.22; 95% CI -0.13 to 0.57; 2 studies; n = 128; low-quality evidence). No effects were observed for rates of therapy completion (RR 0.91; 95% CI 0.68 to 1.20; 2 studies; n = 128; very low-quality evidence).Several studies reported on adverse events. There were no differences between rates of such events in any comparison. We rated several studies as being at 'high' or 'unclear' risk of bias in multiple domains, including for detection bias and attrition bias.

AUTHORS' CONCLUSIONS

We assessed the evidence in this review as mostly low to very low quality. Evidence showed that individual trauma-focused psychological therapy delivered alongside SUD therapy did better than TAU/minimal intervention in reducing PTSD severity post-treatment and at long-term follow-up, but only reduced SUD at long-term follow-up. All effects were small, and follow-up periods were generally quite short. There was evidence that fewer participants receiving trauma-focused therapy completed treatment. There was very little evidence to support use of non-trauma-focused individual- or group-based integrated therapies. Individuals with more severe and complex presentations (e.g. serious mental illness, individuals with cognitive impairment, and suicidal individuals) were excluded from most studies in this review, and so the findings from this review are not generalisable to such individuals. Some studies suffered from significant methodological problems and some were underpowered, limiting the conclusions that can be drawn. Further research is needed in this area.

Standard EMDR Protocol for Alcohol and Substance Dependence Comorbid With Posttraumatic Stress Disorder: Four Cases With 12-Month Follow-Up

This report begins with a summary of the literature regarding the theoretical models behind the comorbid relationship between posttraumatic stress disorder and substance use disorders and the various modified addiction protocols formulated to assist in treating these disorders. This case series outlines the effect that the standard eye movement desensitization and reprocessing (EMDR) protocol had on alcohol and substance dependence for 4 patients who attended our Post Traumatic Stress Clinic in Fremantle, Western Australia, primarily for treatment for posttraumatic stress disorder. Patients were assessed for substance use disorders using the Mini International Neuropsychiatric Interview Plus prior to, immediately after, and 12 months after completing EMDR therapy. Results indicate that the standard EMDR protocol was successful in reducing alcohol and substance use. Prior to treatment, 3 patients met criteria for alcohol dependence and 1 met criteria for substance dependence. At 12-month follow-up, 3 out of 4 clients did not meet the diagnostic criteria for current alcohol dependence or current substance dependence. The implications of these findings are discussed with reference to theories of comorbid posttraumatic stress disorder and substance use disorder and the modified EMDR protocols developed for patients with substance dependence.

A synthesis of the literature on trauma-informed care

Patients with a history of traumatic life events can become distressed or re-traumatized as the result of healthcare experiences. These patients can benefit from trauma-informed care that is sensitive to their unique needs. However, despite the widespread prevalence of traumatic life experiences such as sexual assault and intimate partner violence, trauma-informed care has not been widely researched or implemented. The purpose of this synthesis of the literature is to examine existing research on trauma-informed care for survivors of physical and sexual abuse. The following themes are discussed: trauma screening and patient disclosure, provider-patient relationships, minimizing distress and maximizing autonomy, multidisciplinary collaboration and referrals, and trauma-informed care in diverse settings. This synthesis also explores implications for trauma-informed care research, practice and policy. The themes identified here could be used as a framework for creating provider and survivor educational interventions and for implementing trauma-informed care across disciplines. The findings of this synthesis support further research on patient and provider experiences of trauma-informed care, and research to test the efficacy of trauma-informed care interventions across healthcare settings. Universal implementation of trauma-informed care can ensure that the unique needs of trauma survivors as patients are met, and mitigate barriers to care and health disparities experienced by this vulnerable population.

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.

Helping vulnerable populations: a comprehensive review of the treatment outcome literature on substance use disorder and PTSD

We review treatment studies for comorbid substance use disorder (SUD) and posttraumatic stress disorder (PTSD). Results show positive outcomes on multiple domains. Most models had more effect on PTSD than SUD, suggesting SUD is harder to treat. Seeking Safety (SS) is the most studied model. It shows positive outcomes, and is the only treatment outperforming a control on both PTSD and SUD. Partial-dose SS had more mixed results than the full dose. This first-generation of PTSD/SUD research addresses complex samples excluded from "gold standard" PTSD-alone literature. Treatments for PTSD/SUD are generally longer than PTSD-alone treatments and present-focused, emphasizing stabilization and coping. The few models with past-focused (exposure-based) components also incorporated present-focused approaches for these vulnerable clients. We discuss public health perspectives to advance the field.

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.

Randomized trial comparison of emotion regulation and relational psychotherapies for PTSD with girls involved in delinquency

Posttraumatic stress disorder (PTSD) is prevalent in youth involved in delinquency, but it is often not effectively treated. A randomized clinical trial was conducted comparing the outcomes of an emotion regulation therapy (Trauma Affect Regulation: Guide for Education and Therapy, or TARGET) with a relational supportive therapy (Enhanced Treatment as Usual, or ETAU) with 59 delinquent girls (age 13-17 years) who met criteria for full or partial PTSD. Mixed model regression analyses demonstrated generally large effects for pre-post change in PTSD symptoms for both therapies but not in emotion regulation. Both therapies had small to medium effect size changes in anxiety, anger, depression, and posttraumatic cognitions. Treatment × Time interactions showed small to medium effects favoring TARGET for change in PTSD (intrusive reexperiencing and avoidance) and anxiety symptoms, posttraumatic cognitions, and emotion regulation, and favoring ETAU for change in hope and anger. Results provide preliminary support for TARGET as a potentially efficacious therapy for PTSD with delinquent girls. Relational therapies such as ETAU also may be beneficial for delinquent girls with PTSD, particularly to enhance optimism and self-efficacy and reduce anger.

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.

Cognitive-behavioral treatment for posttraumatic stress disorder in children and adolescents

Several cognitive-behavioral therapy (CBT) approaches are available for treating child and adolescent posttraumatic stress disorder (PTSD). These treatments include common elements (eg, psychoeducation, gradual exposure, relaxation). This review (1) delineates common elements in CBT approaches for treating child and adolescent PTSD; (2) provides a detailed review of three CBT approaches with substantial evidence of effectiveness; and (3) describes promising practices in the area of CBT approaches to treating child and adolescent PTSD. Cultural and implementation considerations are also included.

Psychological trauma and substance abuse: the need for an integrated approach

There is consensus that an integrated approach which addresses the clinical needs of individuals who have histories of substance abuse and psychological trauma concurrently is an acceptable and preferred approach to treatment. Several integrated models have emerged in recent years. In this paper we first define the concepts of substance abuse and psychological trauma, investigate the relationship between both and proceed to discuss why an integrated approach is most compelling. Finally, we review and critically examine the different integrated models that have been developed in terms of efficacy, effectiveness and empirical evidence. The paper concludes with suggestions on how the field can be improved.

New psychotherapies for mood and anxiety disorders

OBJECTIVE

To discuss psychotherapies for depression and anxiety that have emerged in recent years and to evaluate their current level of empirical support.

METHOD

An electronic and a manual literature search of psychotherapies for mood and anxiety disorders were conducted.

RESULTS

Five new therapies for mood disorders and 3 interventions for posttraumatic stress disorder with co-occurring substance abuse met criteria for inclusion in this review. Fewer psychotherapies have been developed for other anxiety disorders. Although research for some of the psychotherapies has demonstrated superiority to usual care, none have firmly established efficacy or specific benefits over other established psychotherapies.

CONCLUSIONS

A plurality of the new psychotherapies introduced and established in the past 5 years have been different assimilations of previously established cognitive-behavioural, interpersonal, or psychodynamic models. While initial results are promising for some, more rigorous efficacy trials and replications are necessary before conclusions can be drawn regarding their relative benefits.