Dialectical Behavior Therapy and Cognitive Processing Therapy Delivered Sequentially to a Woman Veteran: A Promising Alternative to Concurrent Dialectical Behavior Therapy–Prolonged Exposure

Post-traumatic stress disorder (PTSD) and borderline personality disorder (BPD) are complex and chronic conditions that result in impairment across a number of clinically significant domains. Although the two diagnoses reflect distinct clinical syndromes, they often present comorbidly. Furthermore, the comorbidity of the two diagnoses predicts increased symptomatology and may also result in treatment difficulties that would not arise when treating PTSD without a concurrent BPD diagnosis. The challenging nature of comorbid PTSD and BPD diagnoses has led to an increased interest in integrative approaches to treating both diagnoses together. Recent research has suggested that the integration of prolonged exposure (PE; an evidence-based therapy for PTSD) and dialectical behavior therapy (DBT; an evidence-based therapy for BPD) into one treatment approach (CBT–PE) can offer superior outcomes when compared to treating each diagnosis separately. However, at this time, the literature does not document any such examinations with regards to cognitive processing therapy (CPT), another evidence-based therapy for PTSD. This paper reflects a first step towards exploring the integration of CPT and DBT. In this case, a female-identified military Veteran seeking care at a Veterans Affairs healthcare system was treated utilizing integrated, though sequential, CPT and DBT. The clinical results of this case are discussed, as are the implications for other clinicians considering integrating CPT and DBT.

Exposure in an Increasingly Bilingual World: Native Language Exposure Therapy With a Non-Language Matched Therapist

Language is an essential part of psychotherapy and experts in cultural competence encourage the consideration of language as an element in cultural adaptation to therapy. Providing clients with services in their native language is associated with lower dropout and better outcomes. Therapies such as prolonged exposure therapy (PET) for posttraumatic stress disorder (PTSD) require clients to recount trauma memories to activate and correct overreactive fear networks in the brain. Research shows that the most genuine and detailed recall of these autobiographical memories occurs when people recollect in the same language in which the memory was encoded. Clients are less likely to drop out, tend to see better outcomes, and most closely follow the treatment protocol for PET when speaking in their native language. In an increasingly bilingual world, therapists may share a common language with a client but may be unable to speak the client’s native language. A novel solution for PET involves starting therapy in the therapist/client dyad’s shared language and then eventually conducting imaginal exposures in the client’s native language. The following case provides a successful example for how and why such therapy can be conducted.

Examining the nonresponse phenomenon: Factors associated with treatment response in a national sample of veterans undergoing residential PTSD treatment

OBJECTIVE

Although several treatments for PTSD have demonstrated efficacy, a substantial portion of patients do not experience clinically significant improvement. Predictors of treatment response are poorly understood. The current study was designed to investigate predictors of PTSD symptom change in a large national sample of treatment-seeking Veterans with PTSD.

METHOD

We analyzed predictors of treatment response among Veterans engaged in residential PTSD treatment from 2012 to 2013 (N = 2715). Multilevel modeling was used to assess the association between individual-level factors and symptom improvement from treatment entry to post-discharge. Guided by the theory of Resources, Life Events and Changes in Psychological States, we hypothesized that individuals with greater psychological, social/contextual, material, and physical health resources would exhibit better treatment response.

RESULTS

In adjusted analyses, accounting for facility, factors that predicted better treatment response included female gender, more psychological and social/contextual protective factors, and more years of education. Factors that predicted worse treatment response included Black race, comorbid personality disorder, greater pain severity, and current application for disability-related compensation.

CONCLUSIONS

These findings highlight factors that place individuals at risk of poor treatment response. Treatment modifications may be needed in order to optimize response for subgroups who are less likely to benefit from residential PTSD treatment.