Psychotherapeutic Interventions for Symptom Reduction in Veterans With PTSD: An Observational Study in a Residential Clinical Setting

Cognitive processing therapy (CPT) and eye movement desensitization and reprocessing (EMDR) therapy were compared for veterans in a posttraumatic stress disorder (PTSD) residential program (N = 51) who received individual EMDR and group CPT, individual CPT and group CPT, or trauma group exposure (TGE) therapy. Analyses revealed an overall significant difference on posttest measures of the PTSD Checklist for individual EMDR/group CPT and individual CPT/group CPT when compared to TGE, with no significant difference found between EMDR and CPT. Depression scores were significantly decreased between pre- and posttest for patients who received individual EMDR/group CPT. Results support EMDR and CPT as clinically effective and complementary treatments in residential PTSD treatment programs.     

Trajectories of Response to Treatment for Posttraumatic Stress Disorder

Research on the predictors of response to cognitive-behavioral treatments for PTSD has often produced inconsistent or ambiguous results. We argue this is in part due to the use of statistical techniques that explore relationships among the entire sample of participants rather than homogeneous subgroups. Using 2 large randomized controlled trials of Cognitive Processing Therapy (CPT), CPT components, and Prolonged Exposure, we employed growth mixture modeling to identify distinct trajectories of treatment response and to determine the predictors of those trajectories. We determined that the participants’ trajectories could be best represented by 2 latent classes, which we subsequently labeled responders (87% of the sample) and nonresponders (13% of the sample). Notably, there was not a separate class for partial responders. Assignment to the nonresponder class was associated with receiving the written accounts (WA) component of CPT, a pretreatment diagnosis of major depression (MDD), and more pretreatment hyperarousal symptoms. Thus, it appears that some individuals do not benefit from merely writing about their trauma and processing it with the therapist; they may also need to engage in cognitive restructuring to successfully ameliorate their symptoms. Additionally, those who meet criteria for MDD or have high levels of hyperarousal at the onset of treatment might require additional treatment or support.     

A Controlled Study of Eye Movement Desensitization and Reprocessing (EMDR) for Boys with Conduct Problem

Summary

We suggest that trauma contributes to the development and persistence of conduct problems, and should be addressed. Eye movement desensitization and reprocessing (EMDR) was selected as a promising trauma treatment. Twenty-nine boys with conduct problems in residential or day treatment were randomized into standard care or standard care plus 3 trauma-focused EMDR sessions. The EMDR group showed large and significant reduction of memory-related distress, as well as trends towards reduction of post-traumatic symptoms. The EMDR group also showed large and significant reduction ofproblem behaviors by 2-month follow-up, whereas the control group showed only slight improvement. These findings provide support for EMDR's use as a trauma treatment for boys ages 10-16, as well as support for the hypothesis that effective trauma treatment can lead to reduced conduct problems in this population.     

Homework Completion,Patient Characteristics,and Symptom Change in Cognitive Processing Therapy for PTSD

We evaluated the impact of homework completion on change in PTSD symptoms in the context of two randomized controlled trials of Cognitive Processing Therapy for PTSD (CPT). Female participants (n = 140) diagnosed with PTSD attended at least one CPT session and were assigned homework at each session. The frequency of homework completion was assessed at the beginning of each session and PTSD symptoms were assessed every other session. Piecewise growth models were used to examine the relationship between homework completion and symptom change. CPT version (with vs without the written trauma account) did not moderate associations between homework engagement and outcomes. Greater pretreatment PTSD symptoms predicted more Session 1 homework completion, but PTSD symptoms did not predict homework completion at other timepoints. More homework completion after Sessions 2 and 3 was associated with less change in PTSD from Session 2 to Session 4, but larger pre-to-post treatment changes in PTSD. Homework completion after Sessions 2 and 3 was associated with greater symptom change among patients who had fewer years of education. More homework completion after Sessions 8 and 9 was associated with larger subsequent decreases in PTSD. Average homework completion was not associated with client characteristics. In the second half of treatment, homework engagement was associated with less dropout. The results suggest that efforts to increase engagement in homework may facilitate symptom change.     

Más Allá De Las Barreras: Competency and Practice Considerations in Language,Cultural, and Social Issues When Delivering Group CPT to Hispanic Immigrants

ABSTRACT

High rates of underassessed trauma and psychiatric disorders, particularly post-traumatic 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 article aims to outline these and provide future directions for research.     

A meta-analytic review of cognitive processing therapy for adults with posttraumatic stress disorder

Numerous studies have demonstrated the efficacy of cognitive processing therapy (CPT) for treating posttraumatic stress disorder (PTSD). Two prior meta-analyses of studies are available but used approaches that limit conclusions that can be drawn regarding the impact of CPT on PTSD outcomes. The current meta-analysis reviewed outcomes of trials that tested the efficacy of CPT for PTSD in adults and evaluated potential moderators of outcomes. All published trials comparing CPT against an inactive control condition (i.e. psychological placebo or wait-list) or other active treatment for PTSD in adults were included, resulting in 11 studies with a total of 1130 participants. CPT outperformed inactive control conditions on PTSD outcome measures at posttreatment (mean Hedges’ g = 1.24) and follow-up (mean Hedges’ g = 0.90). The average CPT-treated participant fared better than 89% of those in inactive control conditions at posttreatment and 82% at follow-up. Results also showed that CPT outperformed inactive control conditions on non-PTSD outcome measures at posttreatment and follow-up and that CPT outperformed other active treatments at posttreatment but not at follow-up. Effect sizes of CPT on PTSD symptoms were not significantly moderated by participant age, number of treatment sessions, total sample size, length of follow-up, or group versus individual treatment; but, older studies had larger effect sizes and percent female sex moderated the effect of CPT on non-PTSD outcomes. These meta-analytic findings indicate that CPT is an effective PTSD treatment with lasting benefits across a range of outcomes.     

Massed Cognitive Processing Therapy in Active-Duty Military: A Case Series

Despite consistent evidence that Cognitive Processing Therapy (CPT) is an efficacious treatment for posttraumatic stress disorder (PTSD), the effects among active-duty service members and veterans have been smaller than for civilians. Modifications to standard delivery may be needed to increase treatment engagement and completion, which could improve outcomes in this population. Delivering CPT in a massed format may reduce barriers to care and enable more rapid symptom reduction, yet clinicians and patients may have concerns about the tolerability and practicality of such interventions. This case series describes a course of CPT delivered in 5 days in a mixed group and individual format among 4 active-duty military service members as part of a larger randomized clinical trial. Although the pattern of symptom change differed between patients, most demonstrated clinically significant reductions in PTSD and depression symptoms during the 5-day treatment. Patients reported that the pace was tolerable and that the mixed group and individual format was beneficial. Although further research is needed to understand the longer-term outcomes of massed CPT, this therapy format has important implications for the future delivery of treatments for PTSD.     

Changes in suicidal ideation following cognitive processing therapy in a VA residential treatment program

ABSTRACT

In 2015, suicide accounted for over 44,000 deaths and was the 10th leading cause of mortality in the US. Although Veterans, in general, are at a high risk for suicide, Veterans with Posttraumatic Stress Disorder (PTSD) are at even greater risk. While evidence suggests that PTSD symptoms are reduced by Cognitive Processing Therapy (CPT), little is known about how this treatment impacts changes in suicidal ideation across residential treatment. Studies with active duty personnel have found reductions in suicidal ideation following CPT treatment; however, only one study to date has examined this question in a Veteran sample. The current study examined (a) changes in suicidal ideation across a residential CPT treatment program and (b) the influence of demographic variables on change in suicidal ideation across treatment. Participants (N = 303) were admitted to a residential PTSD treatment in a VA medical center and completed pre-, mid-, and post-treatment assessments. Multilevel modeling of archival data revealed that suicidal ideation significantly decreased over the course of CPT (B = ?0.153, SE =0.028, 95%CI =[?0.21, ?0.10], t= ?5.40, p< .001); however, this change did not differ based on age, marital status, sex, or race/ethnicity. Clinical and research implications are discussed.     

Clinical and Administrative Insights From Delivering Massed Trauma-Focused Therapy to Service Members and Veterans

Despite strong evidence of their effectiveness in reducing symptoms of posttraumatic stress disorder (PTSD), prolonged exposure therapy (PE) and cognitive processing therapy (CPT) remain challenging for some service members and veterans to access and complete. Delivering PE and CPT in time-condensed or “massed” formats may reduce barriers to receiving care. PE and CPT have now been implemented across a range of tempos (e.g., multiple sessions per day across 1 week, one session per day for 3 weeks) and to multiple target populations, in a variety of contexts from individual therapy alone to full intensive outpatient programs. A massed format of treatment delivery has advantages for both patients and providers, including quicker time to recovery, less opportunity for avoidance, and improved treatment completion rates. The time-limited nature of massed treatment also creates accompanying challenges, such as less time to practice homework and greater impact when factors delay or disrupt progress. This paper discusses lessons learned from providers across diverse settings who are experienced in both delivering massed PE and CPT and managing such programs, primarily with military populations.     

Preliminary Development of Trauma-Focused Treatment Groups for Incarcerated Juvenile Offenders

Summary

Most male juvenile offenders have been exposed to trauma. Many juvenile offenders have experienced both acute and chronic trauma. Trauma exposure among offenders is closely linked to their criminal behavior, yet few protocols have been developed to treat posttraumatic sequelae in a delinquent population. This article describes initial efforts to develop group therapy services for incarcerated male juvenile offenders who have histories of significant trauma exposure and current symptoms of PTSD. Four separate pilot groups were conducted in two Massachusetts Department of Youth Service secure residential facilities. The treatment included trauma psychoeducation (including the relationship between trauma and offending), therapeutic trauma exposure through discussion and expressive arts, and coping skill development. The treatment development and initial implementation as well as directions for future research are discussed.     

Intensive Cognitive Processing Therapy Associated With Reduced PTSD Treatment Dropout in a Case-Controlled Study of Treatment-Seeking Veterans

Cognitive Processing Therapy (CPT) is an empirically supported psychotherapy for posttraumatic stress disorder (PTSD). The complex issue of treatment attrition is a frequently cited concern regarding CPT and other evidence-based psychotherapies for PTSD. The current study investigated the feasibility and effectiveness of “intensive” CPT, a treatment-consistent modification of CPT in which sessions are conducted more frequently than standard protocol. Fifty-four military veterans (20% female; M_age = 46; 80% Caucasian) seeking outpatient treatment for PTSD were included in this study. Patients who elected to receive intensive CPT (n = 27) were matched with archival records of individuals who received standard CPT (n = 27). Patients across treatment conditions were matched based on baseline symptom severity as measured by the PTSD Checklist for DSM-5 (PCL-5; M_PCL-5 = 52.61). Treatment outcomes were compared and longitudinal multilevel modeling was used to compare rate of symptom change over time. Patients who elected to engage in intensive CPT were twice as likely to complete treatment (88.9%) as those who received standard CPT (44.4%), X²(1, N = 54) = 12.00, p = .001. On average, intensive CPT patients completed treatment in about 25% of the time as standard CPT patients (33.8 days vs. 125.7 days). Patients in intensive CPT also demonstrated greater benefit: 81.4% reported a clinically significant improvement in PCL-5 scores compared to 51.8% of those in standard CPT, X²(1, N = 54) = 5.33, p = .020, φ = −0.314. Intensive and standard CPT performed comparably in regard to final PCL-5 score, change over time, and screening cutoff. In addition, there were no differences in treatment outcomes based on licensure status of the provider nor whether treatment was delivered in person or virtually. Intensive CPT represents a novel, treatment-consistent adaptation that was utilized to treat a group of veterans with PTSD with minimal treatment dropout. Patients who elected to engage in more frequent treatment were more likely to complete treatment, did so in one quarter of the time, and reported similar to better treatment outcomes. Providers may consider encouraging their patients to participate in treatment as frequently as they are able. However, preliminary findings are based on a nonrandom sample and design limitations temper conclusions.     

Using Client Narratives to Identify Predictors of Outcome in Written Exposure Therapy and Cognitive Processing Therapy

Written exposure therapy (WET) is a brief, five-session treatment for posttraumatic stress disorder (PTSD) that aims to improve access to care. WET has been demonstrated to be an efficacious PTSD treatment with lower rates of dropout and noninferior PTSD symptom outcome compared to cognitive processing therapy (CPT), a 12-session, gold-standard treatment. To identify predictors of treatment outcome in both WET and CPT, the current study examined the content of participants’ written narratives. Participants were 123 adults with PTSD who were randomly assigned to receive WET (n = 61) or CPT (n = 62). The Change and Growth Experiences Scale (CHANGE) coding system was used to code all available narratives in both treatment conditions for variables hypothesized to be relevant to therapeutic change. Linear regression analyses revealed that in WET, higher average levels of accommodated (healthy, balanced) beliefs and an increase in accommodated beliefs from the first to the final impact statement predicted better PTSD symptom outcome at 12 weeks postrandomization. In CPT, higher average levels of overgeneralized and accommodated beliefs and lower levels of avoidance expressed in the narratives predicted better PTSD outcome. There were no significant predictors of outcome in analyses of change from the first to final impact statement in CPT. These findings add to research identifying predictors of change in WET and CPT by highlighting the importance of low avoidance in CPT and of trauma-related cognitions in both CPT and WET, even though WET is a brief written intervention that does not explicitly target cognitive change.     

Motivation-Adaptive Skills-Trauma Resolution (MASTR) Therapy for Adolescents with Conduct Problems

Summary

Trauma is proposed as a key to understanding the development and persistence of adolescent conduct problems, in conjunction with other contributing factors. A trauma-focused individual therapy approach is presented as one example of how this population might be more effectively treated. This approach features motivational interviewing, self-control training (cognitive-behavioral therapy), and trauma resolution (eye movement desensitization and reprocessing). This paper reports on an open trial of six adolescents with school and conduct problems who received school-based Motivation-Adaptive Skills-Trauma Resolution (MASTR) treatment. Reductions in post-traumatic stress, related symptoms, and problem behaviors, along with improved school performance, indicate the value of further study of this treatment approach.     

The Role of Trauma in Conduct Disorder

Summary

Trauma is proposed as a key to understanding the development and persistence of conduct disorder, in conjunction with other contributing factors. Trauma history is ubiquitous in the conduct disordered population, and trauma effects can help to account for many features of conduct disorder, including lack of empathy, impulsivity, anger, acting-out, and resistance to treatment. The current standard of care fails to fully address trauma, which may partially explain the low success rate of extant treatment approaches. A trauma-informed perspective is introduced to current models of conduct disorder. Research, prevention, and treatment implications are discussed.     

Implementation of Cognitive Therapy for PTSD in routine clinical care: Effectiveness and moderators of outcome in a consecutive sample

ObjectiveTrauma-focused psychological treatments are recommended as first-line treatments for Posttraumatic Stress Disorder (PTSD), but clinicians may be concerned that the good outcomes observed in randomized controlled trials (RCTs) may not generalize to the wide range of traumas and presentations seen in clinical practice. This study investigated whether Cognitive Therapy for PTSD (CT-PTSD) can be effectively implemented into a UK National Health Service Outpatient Clinic serving a defined ethnically mixed urban catchment area.MethodA consecutive sample of 330 patients with PTSD (age 17–83) following a wide range of traumas were treated by 34 therapists, who received training and supervision in CT-PTSD. Pre and post treatment data (PTSD symptoms, anxiety, depression) were collected for all patients, including dropouts. Hierarchical linear modeling investigated candidate moderators of outcome and therapist effects.ResultsCT-PTSD was well tolerated and led to very large improvement in PTSD symptoms, depression and anxiety. The majority of patients showed reliable improvement/clinically significant change: intent-to-treat: 78.8%/57.3%; completer: 84.5%/65.1%. Dropouts and unreliable attenders had worse outcome. Statistically reliable symptom exacerbation with treatment was observed in only 1.2% of patients. Treatment gains were maintained during follow-up (M = 280 days, n = 220). Few of the selection criteria used in some RCTs, demographic, diagnostic and trauma characteristics moderated treatment outcome, and only social problems and needing treatment for multiple traumas showed unique moderation effects. There were no random effects of therapist on symptom improvement, but therapists who were inexperienced in CT-PTSD had more dropouts than those with greater experience.ConclusionsThe results support the effectiveness of CT-PTSD and suggest that trauma-focused cognitive behavior therapy can be successfully implemented in routine clinical services treating patients with a wide range of traumas.     

Internet-based self-help treatment for panic disorder: a randomized controlled trial comparing mandatory versus optional complementary psychological support

Panic disorder (PD) is one of the most common psychiatric disorders. Web-based self-help treatments for PD have had promising results. These online treatments seem to have larger effect sizes (ESs) when professional support is added. However, the amount of support or how it should be administered is not yet clear. The aim of this trial was to study two ways of administering psychological support provided by phone as a part of Internet-based self-help treatment for PD based on cognitive behavioral therapy. Seventy-seven participants diagnosed with PD were randomly assigned to one of three experimental conditions: a waiting list control group; a treatment group with non-scheduled psychological support; or a treatment group with scheduled psychological support. PD symptoms of participants who received treatment improved significantly compared to the control group (mean ES d = 1.18, p < .05). In addition, there were statistically and clinically significant differences between treatment groups (Mean difference = ?3.20, p = .005, 95% CI [?5.62, ?.79]). The scheduled group showed a larger ES, a lower dropout rate, and better adherence to treatment than the non-scheduled group. Scheduled support seems to be indicated for patients who seek Web-based treatment for PD, and their symptoms of panic, anxiety, and depression improve at post-treatment and six-month follow-up. In contrast, when support depends on patient demand, they receive less support and so, the therapeutic effect is poorer.     

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.     

Cognitive Mediators of Treatment for Social Anxiety Disorder: Comparing Acceptance and Commitment Therapy and Cognitive-Behavioral Therapy

Objective

To assess the relationship between session-by-session mediators and treatment outcomes in traditional cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for social anxiety disorder.

Method

Session-by-session changes in negative cognitions (a theorized mediator of CBT) and experiential avoidance (a theorized mediator of ACT) were assessed in 50 adult outpatients randomized to CBT (n = 25) or ACT (n = 25) for DSM-IV social anxiety disorder.

Results

Multilevel modeling analyses revealed significant nonlinear decreases in the proposed mediators in both treatments, with ACT showing steeper decline than CBT at the beginning of treatment and CBT showing steeper decline than ACT at the end of treatment. Curvature (or the nonlinear effect) of experiential avoidance during treatment significantly mediated posttreatment social anxiety symptoms and anhedonic depression in ACT, but not in CBT, with steeper decline of the Acceptance and Action Questionnaire at the beginning of treatment predicting fewer symptoms in ACT only. Curvature of negative cognitions during both treatments predicted outcome, with steeper decline of negative cognitions at the beginning of treatment predicting lower posttreatment social anxiety and depressive symptoms.

Conclusions

Rate of change in negative cognitions at the beginning of treatment is an important predictor of change across both ACT and CBT, whereas rate of change in experiential avoidance at the beginning of treatment is a mechanism specific to ACT.     

A Single-Arm Meta-Analysis of Cognitive Processing Therapy in Addressing Trauma-Related Negative Cognitions

Cognitive Processing Therapy (CPT) is a first-line treatment for posttraumatic stress disorder designed to address cognitive “stuck points” connected to a patient’s trauma-related negative cognitions (NCs). Although CPT has well-established efficacy, the ability of CPT to address NCs remains understudied. The purpose of this study was to conduct a single-arm meta-analysis to determine the overall effect of CPT in attenuating NCs pre- to posttreatment across multiple clinical trials. A review of the existing literature was performed with only peer-reviewed clinical trials included in the meta-analysis. Nine studies with data from 583 participants were entered into the meta-analysis. CPT was found to have a large effect size in reducing NCs from pre- to posttreatment. Findings are limited by the single-arm nature of analyses and heterogeneity in included trial methodology (e.g., gender, trauma type, civilian versus veteran).     

The Effect of PTSD Symptom Change on Suicidal Ideation in a Combined Military and Civilian Sample Engaged in Cognitive Processing Therapy

In light of the well-established relationship between posttraumatic stress disorder (PTSD) and suicidal ideation (SI), there has been a push for treatments that simultaneously improve symptoms of PTSD and decrease SI. Using data from a randomized controlled hybrid implementation-effectiveness trial, the current study investigated the effectiveness of Cognitive Processing Therapy (CPT; Resick, Monson, & Chard, 2016) on PTSD and SI. The patient sample (N = 188) was diverse in military and veteran status, gender, and comorbidity, and 73% of the sample endorsed SI at one or more points during CPT. Participants demonstrated significant improvement in SI over the course of CPT. Multilevel growth curve modeling revealed a significant association between PTSD symptom change and change in SI. Results from cross-lagged multilevel regressions indicated that PTSD symptoms predicted SI in the next session, yet SI in a given session did not predict PTSD symptoms in the next session. Potentially relevant clinical factors (i.e., military status, gender, depression diagnosis, baseline SI, study consultation condition) were not associated with the relationship between PTSD symptoms and SI. These results add to the burgeoning literature suggesting that evidence-based treatments for PTSD, like CPT, reduce suicidality in a range of individuals with PTSD, and that this reduction is predicted by improvements in PTSD symptoms.