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.     

Intensive Outpatient Program Using Prolonged Exposure for Combat-Related PTSD: A Case Study

Although prolonged exposure (PE) has been identified as a first-line treatment for posttraumatic stress disorder (PTSD), research has found that military service members and veterans have smaller reductions in symptom severity compared to civilians. The nature of trauma in a deployed combat setting and the unique complexities of military culture have been proposed as explanations for greater rates of PTSD and poorer treatment response to first-line psychotherapies in military and veteran populations. This paper presents a case study to highlight how a novel, intensive outpatient program utilizing prolonged exposure therapy (IOP-PE) may benefit military personnel with combat-related PTSD. The patient is a Caucasian man in his early 40s seeking treatment for PTSD after more than 10 years of enlisted, active duty military service across two branches and three combat deployments. The IOP-PE includes the standard PE components and eight, nonstandard treatment augmentations tailored for military personnel. In contrast to standard PE, which typically is delivered weekly over several months, IOP-PE consists of 15 daily, 90-minute PE sessions conducted over 3 weeks. The patient demonstrated large reductions on the Clinician-Administered PTSD Scale (28 points) and PTSD Checklist (48 points) by the 6-month posttreatment follow-up point. Findings provide support for conducting further research that determines whether IOP-PE is effective and tolerable in military and veteran populations.     

Prolonged exposure in patients with chronic PTSD: predictors of treatment outcome and dropout

The present study investigated predictors of treatment outcome and dropout in two samples of PTSD-patients with mixed traumas treated using prolonged imaginal exposure. Possible predictors were analysed in both samples separately, in order to replicate in one sample findings found in the other. The only stable finding across the two groups was that patients who showed more PTSD-symptoms at pre-treatment, showed more PTSD-symptoms at post-treatment and follow-up. Indications were found that benzodiazepine use was related to both treatment outcome and dropout, and alcohol use to dropout. Demographic variables, depression and general anxiety, personality, trauma characteristics, feelings of anger, guilt, and shame and nonspecific variables regarding therapy were not related to either treatment outcome or dropout, disconfirming generally held beliefs about these factors as contra-indications for exposure therapy. It is concluded that it is difficult to use pre-treatment variables as a powerful and reliable tool for predicting treatment outcome or dropout. Clinically seen, it is therefore argued that exclusion of PTSD-patients from prolonged exposure treatment on the basis of pre-treatment characteristics is not justified.     

The Nature,Timing, and Symptom Trajectories of Dropout From Transdiagnostic and Single-Diagnosis Cognitive-Behavioral Therapy for Anxiety Disorders

Dropout from psychotherapy is common and can have negative effects for patients, providers, and researchers. A better understanding of when and why patients stop treatment early, as well as actionable factors contributing to dropout, has the potential to prevent it. Here, we examined dropout from a large randomized controlled trial of transdiagnostic versus single-diagnosis cognitive-behavioral treatment (CBT) for patients with anxiety disorders (n = 179; Barlow et al., 2017). We aimed to characterize the timing of and reasons for dropout and test whether participants who dropped out had different symptom trajectories than those who completed treatment. Results indicated that overall, the greatest risk of dropout was prior to the first treatment session. In single-diagnosis CBT, dropout risk was particularly elevated before the first session and after other early sessions, whereas in transdiagnostic CBT, dropout risk was low and stable before and during treatment. Participants most often dropped out due to failure to comply with study procedures or dissatisfaction with or desiring alternative treatment. Results from multilevel models showed that trajectories of anxiety symptoms did not significantly differ between dropouts and completers. These findings suggest that there may be specific time windows for targeted and timely interventions to prevent dropout from CBT.     

Feasibility and Acceptability of Group-Facilitated Prolonged Exposure Therapy for PTSD in VA Residential Rehabilitation Treatment Programs

Prolonged Exposure therapy (PE) is a first-line treatment for posttraumatic stress disorder (PTSD); however, few VA patients receive this treatment. One of the barriers to PE receipt is that it is only available in an individual (one-on-one) format, whereas many VA mental health clinics provide the majority of their psychotherapy services in group format. In particular, PTSD residential rehabilitation treatment programs (RRTPs) offer most programming in group format. Consequently, strategies are needed to improve the scalability of PE by adapting it to fit the delivery setting. The current study was designed to pilot test a group-facilitated format of PE in RRTPs. Thirty-nine Veterans who were engaged in care in the PTSD RRTP at a Midwestern VA were recruited to participate in a Group-facilitated PE protocol. Participants engaged in twelve 90-minute sessions of Group PE over the course of 6 weeks, plus six 60-minute individual sessions for imaginal exposure. Group treatment followed the PE model and consisted of psychoeducation, treatment rationale, and in vivo exposure to reduce trauma-related avoidance and thereby improve PTSD symptoms. PTSD symptoms were measured via the PTSD Checklist for DSM-5 (PCL-5) and depression symptoms were measured via the Patient Health Questionnaire (PHQ-9) at baseline, endpoint (6 weeks), and at 2-month follow-up. Thirty-nine individuals initiated Group-facilitated PE and 34 completed treatment. The average number of group sessions attended was 11 out of 12. Acceptability ratings were high. Mean change (improvement) in the intent-to-treat sample at 2-month follow-up was 20.0 points on the PCL-5 (CI 18.1, 21.9; Cohen’s d = 1.1) and 4.8 points on the PHQ-9 (CI 4.1, 5.5, d = .8). These results suggest that adapted evidence-based interventions for PTSD can improve treatment access and efficiency for the RRTP setting. A group-based approach has the potential to improve the scalability of PTSD treatment by reducing required resources. A fully powered trial is now needed to test the effectiveness of Group-facilitated PE in the RRTP setting.     

Conducting Prolonged Exposure for PTSD During the COVID-19 Pandemic: Considerations for Treatment

The unprecedented effects and duration of the COVID-19 crisis are likely to elevate the population’s level of anxiety due to psychological stress, economic hardship, and social isolation. This effect may be especially potent for individuals with preexisting mental health conditions, such as posttraumatic stress disorder (PTSD). Prolonged Exposure (PE) therapy is a highly effective treatment for PTSD across trauma-exposed populations, and has been implemented effectively via telehealth. Nevertheless, PE implementation via telehealth may require specific adaptations during the COVID-19 crisis due to public health mandates calling for sheltering in place and physical distancing. This paper discusses strategies for implementing PE for PTSD during the COVID-19 pandemic, which may also be applied to other situations in which physical distancing must be considered.     

Adult Influence on the Participation of Peers Without Disabilities in Peer Support Programs

Three peers without disabilities who volunteered to serve as peer supports and were identified by general education teachers as having academic difficulties were studied across three conditions. In baseline, a peer without disabilities worked alone, while the student with severe disabilities was supervised by an adult. In the Peer Support condition, peers without disabilities worked with the student with severe disabilities, and both individuals were supervised by an adult. In the Adult Involvement condition, peers without disabilities were supervised by an adult as in the Peer Support condition, but peers worked separately from the student with severe disabilities. Dependent measures included the active engagement of peers without disabilities and students with severe disabilities, and social interactions between students and peers. Our data indicate that the Peer Support and Adult Involvement conditions resulted in higher, but similar, levels of active engagement for two of three peers without disabilities when compared to baseline. For the third peer, high levels of active engagement occurred across all conditions. Active engagement varied across students with severe disabilities, but was typically highest in conditions where peers without disabilities were involved. For all students with severe disabilities, social interactions were more frequent and longer in the Peer Support condition.     

Exposure,Loss, and Support Predicting the Dimensions of Posttsunami Trauma

This study examined whether exposure, resource loss, and social support predicted the posttsunami trauma of PTSD, depression, negative affect, and physical health problems of the 2004 tsunami survivors. Four hundred sixteen survivors were interviewed in Tamil Nadu (India) 14 months posttsunami. Loss of life followed by loss of property and disaster exposure positively predicted the dimensions of trauma. Survivors having lower social status and income received less material and informational support than their equally affected counterparts, which furthered stress and distress. The survivors’ trauma can be arrested, minimizing the exposure and tangible resource loss, and improving the delivery of social support.     

Using Prolonged Exposure and Cognitive Processing Therapy to Treat Veterans With Moral Injury-Based PTSD: Two Case Examples

Moral injury refers to acts of commission or omission that violate individuals’ moral or ethical standards. Morally injurious events are often synonymous with psychological trauma, especially in combat situations—thus, morally injurious events are often implicated in the development of posttraumatic stress disorder (PTSD) for military service members and veterans. Although prolonged exposure (PE) and cognitive processing therapy (CPT) have been well established as effective treatments for veterans who are struggling with PTSD, it has been suggested that these two evidence-based therapies may not be sufficient for treating veterans whose PTSD resulted from morally injurious events. The purpose of this paper is to detail how the underlying theories of PE and CPT can account for moral injury-based PTSD and to describe two case examples of veterans with PTSD stemming from morally injurious events who were successfully treated with PE and CPT. The paper concludes with a summary of challenges that clinicians may face when treating veterans with PTSD resulting from moral injury using either PE or CPT.     

Keeping Engaged During Deployment: The Interplay Between Self-Efficacy,Family Support,and Threat Exposure

This study investigated the importance of 2 resilience resources for service members’ ability to deal with threat during deployment. Military self-efficacy and family support were measured before deployment and related to work engagement and burnout levels of service members during deployment. We hypothesized that in high threat situations, low self-efficacy would lead to unfavorable outcomes, whereas in low threat situations, high self-efficacy could have negative consequences. In addition, we hypothesized that family support would compensate for both effects. The results showed these expected 3-way interactions. We found that strong self-efficacy helped service members deal with exposure to threatening situations during deployment, leading to more work engagement and less burnout. However, having strong self-efficacy without being exposed to threat during deployment reduced service members’ work engagement and increased burnout. In addition, we found that the presence of family support compensated for these effects. Service members with low self-efficacy benefitted from family support when threat exposure was high, whereas service members with high self-efficacy benefitted from family support when threat exposure was low. As such, family support seemed to act as a compensatory mechanism for the potential negative effects of self-efficacy. This underlines the importance of studying the interplay between resources that help service members deal with deployment experiences. Practical implications relate to supporting service members’ resilience through enhancing multiple resources.     

Children's Anticipated Responses to Hypothetical Peers With Undesirable Characteristics: Role of Peers' Desire to Change,Effort to Change,and Outcome

The authors explored the extent to which 5th- and 6th-grade students’ anticipated responses to hypothetical peers with undesirable characteristics (e.g., being overweight) are influenced by information that each peer (a) desired (or did not desire) to change the characteristic, (b) exerted effort (or did not exert effort) to change the characteristic, and (c) was successful (or unsuccessful) in changing the characteristic. In general, the children anticipated responding more favorably to peers who were successful in overcoming an undesirable characteristic than those who were unsuccessful. However, across both outcome conditions, peers who wanted to change and exerted effort to change were rated more favorably than were peers who reported no effort to change an undesirable characteristic, regardless of whether or not they had expressed a desire to change that characteristic. For peers whose failure to change an undesirable characteristic was associated with no effort to change, those who expressed a desire to change were rated more favorably than those who expressed no desire to change.     

The development of social aggression and physical aggression: A narrative analysis of interpersonal conflicts

Using conflict narratives reported by children and adolescents, this study investigated the development and social functions of social aggression in comparison to physical aggression. A total of 510 participants in two cohorts of a longitudinal study were involved (116 girls and 104 boys from Grade 4 and155 girls and 135 boys from Grade 7). Patterns of social aggression and physical aggression were identified based on interview reports in the first year of the study. Results showed that a triadic structure of social relationship was often reported in conflicts where social aggression was employed, whereas a dyadic structure was reported in conflicts involving physical aggression. Girls tended to use social aggression against girls, whereas boys tended to use physical aggression against boys. Children and adolescents who were central in peer social networks were more likely to employ social aggression than those who were peripheral in the networks. Social aggression was not reliably linked to concurrent or future problematic adjustment. Physical aggression, however, was not related to network centrality but was linked to concurrent and future maladjustment (e.g., low academic competence and school dropout). Aggr. Behav. 28:341–355, 2002. © 2002 Wiley‐Liss, Inc.     

Acceptability and Feasibility of an Intervention to Enhance Social Group Belonging: Evidence From Three Trials of Groups 4 Health

Groups 4 Health (G4H) is a group psychotherapy program that targets social group disconnection. An emerging evidence base supports its efficacy in reducing loneliness, depression, and social anxiety. However, to date there has been no formal analysis of its acceptability to clients and therapists, nor an investigation of its feasibility for wider implementation. This input from end users is crucial to ensure the program’s wider suitability and to contribute to its improvement. This study drew data from three clinical trials, including 266 G4H clients and 68 G4H therapists. From the Phase III trial only, additional data were available from 90 clients in a dose-controlled cognitive-behavioral therapy (CBT) comparison group, and focus groups/interviews with 6 therapists and 13 clients. Client satisfaction was high, with all average ratings >7/10, significantly exceeding the CBT comparison group. Therapist satisfaction with each module was >5/7. Retention was >80%. Homework completion was high, with <10% of clients saying that they had not attempted the homework. Therapists and clients both emphasized the benefits arising from G4H, and the contribution of the group context itself as a vehicle to achieve positive outcomes.     

Peer support for women with breast cancer: the role of empathy and self‐disclosure

This study examined how women with breast cancer perceived different styles of peer helping. Forty recently diagnosed breast cancer patients evaluated three audiotaped conversations between a breast cancer patient and an (ex‐patient) volunteer helper; the conversations differed in terms of the empathy and self‐disclosure offered by the helper. The findings supported the first hypothesis, that a helping style involving high self‐disclosure would be positively evaluated only in the presence of high empathy. However, the findings did not support the second hypothesis, that in conversations where high empathy is present, a helping style involving high self‐disclosure would be evaluated more positively than one involving low self‐disclosure. Qualitative data suggested that the helper's ability to listen to the patient and the helper's appropriate sharing of her own experience of breast cancer were both perceived as important components of effective helping. Implications for the training and practice of volunteer helpers are discussed. Copyright © 1999 John Wiley & Sons, Ltd.     

Community based cognitive therapy in the treatment of posttraumatic stress disorder following the Omagh bomb

Studies in academic research centres with selected patients have shown that several cognitive behaviour therapies are effective in the treatment of PTSD following traumas affecting individuals or small groups. Little information is available on the extent to which these positive findings will generalize to more routine clinical settings with less selected patients or to a trauma that affects a whole community. The present study addresses these generalization issues. A consecutive series of 91 patients with PTSD resulting from a car bomb which exploded in the centre of Omagh, Northern Ireland in August 1998 were treated with cognitive therapy, along lines advocated by Ehlers and Clark (2000). There were no major exclusion criteria and 53% of patients had an additional axis I disorder (comorbidity). Therapists were NHS staff with heavy caseloads and modest prior training in CBT for PTSD. A brief training in specialist procedures for PTSD was provided. Patients received an average of eight treatment sessions. Significant and substantial improvements in PTSD were observed. Degree of improvement was comparable to that in previously reported research trials. Comorbidity was not associated with poorer outcome, perhaps because comorbid patients were given more sessions of treatment (average 10 vs 5 sessions). Patients who were physically injured improved less than those who were not physically injured. Overall, the results indicate that the positive findings obtained in research settings generalize well to a frontline, non-selective service.     

创伤后应激障碍对青少年生活满意度的影响：社会支持的调节作用

采用问卷法对雅安地震2.5年后的397名中学生进行测试,考察创伤后应激障碍及其各维度对生活满意度的影响,并检验社会支持在其中的调节作用。结果发现,侵入性症状、负性认知和情绪改变症状、警觉性增高症状和PTSD总分负向预测生活满意度,回避性症状对生活满意度预测作用不显著;社会支持在警觉性增高症状、回避性症状、PTSD总分与生活满意度之间起调节作用,社会支持在侵入性症状、负性认知和情绪改变症状与生活满意度之间不起调节作用。     

Understanding Social Factors in the Context of Trauma: Implications for Measurement and Intervention

One of the most important factors predicting the presence of posttraumatic stress disorder (PTSD) after trauma exposure is social support, yet the construct is theoretically complex and remains variably defined. To better inform the trauma literature on the impact of social factors, a theoretical review of social support and PTSD was conducted, and implications for measurement and intervention are outlined. Type of trauma, sex of participant, timing of social support, and support providers are described as significant moderators of the association between social factors and PTSD. The developmental trajectory of the association between social factors and PTSD occurrence is outlined, emphasizing the positive influence of social support initially following trauma, and the deterioration effect of PTSD symptoms on social support over the longer term. Possibilities for future research and intervention at multiple levels and at different time points are described.     

青少年的情绪调节策略对创伤后应激障碍和创伤后成长的影响:社会支持的调节作用

为了考察雅安地震后青少年的情绪调节策略、社会支持与创伤后应激障碍(PTSD)和创伤后成长(PTG)之间的关系,采用创伤暴露程度问卷、情绪调节策略问卷、社会支持问卷、儿童创伤后应激障碍症状量表和创伤后成长问卷对雅安市芦山县的315名中学生进行调查,结果发现:创伤暴露程度对认知重评和表达抑制的预测作用不显著,对PTSD和PTG具有显著的正向预测作用。青少年的认知重评策略可以显著地负向预测PTSD、正向预测PTG,表达抑制策略仅对PTSD有显著的正向预测作用、对PTG的预测作用不显著;社会支持可以显著地调节表达抑制策略对PTSD和PTG的作用,表现为表达抑制对PTSD的正向预测作用随着社会支持的增加而降低,并可随着社会支持的增加而对PTG发挥促进作用。