A preliminary investigation of sudden gains in exposure therapy for PTSD

The purpose of the current study was to examine sudden gains in those receiving treatment for PTSD and whether these rapid changes were related to overall symptom reduction in a small sample of female assault survivors with PTSD undergoing prolonged exposure (PE) therapy. Sudden gains were found to occur in 52% of the sample. Among those who experienced a sudden gain, the average magnitude (12.4 points) accounted for 61% of overall symptom reduction. Importantly, treatment outcome was better for those who experienced sudden gains than those who did not. The experience of a sudden gain may result in patients becoming more fully engaged with treatment, and recognition of them may result in identifying potential process-related predictors of treatment response.     

Hope in the Supervision of Therapy of Patients with Psychotic Disorders

Abstract

Psychotherapeutic interventions for individuals diagnosed with psychotic disorders have been extensively reviewed and studied (Fromm-Reichmann, 1950; Searles, 1965; Rosenfeld, 1988) and have recently received further attention (Kanwal, 1997; Silver, 2001; Spinelli, 2001). Nevertheless, there are almost no updated articles on the supervision of this therapy. This article addresses the issue, focusing on the importance of a sense of hope among therapists working with individuals who have psychotic disorders.     

Impact of emotional approach coping and hope on PTSD and depression symptoms in a trauma exposed sample of Veterans receiving outpatient VA mental health care services

Abstract

The present investigation evaluates the relationship between coping style, dispositional hope, and posttraumatic stress disorder (PTSD) and depression symptom severity in a trauma-exposed Veteran sample. Specifically, we evaluated the adaptive value of emotional avoidant and approach coping strategies and perceptions of hope in a sample of 209 trauma-exposed Veterans receiving outpatient mental health care at a VA facility. Participants completed a life events questionnaire and inventories assessing coping, dispositional hope, and PTSD and depression symptom severity. Hierarchical regression analyses were conducted controlling for relevant demographic variables. Greater levels of emotional avoidance and lower levels of emotional expression were significantly associated with increased PTSD and depression symptom severity. Dispositional hope was positively associated with depression symptoms only and perceptions of hope moderated the association between emotional avoidance coping and depression symptoms. Findings highlight the value of emotional coping strategies and perceptions of hope in posttraumatic adjustment. Specifically, employing coping techniques that encourage emotional expression may promote improved adjustment among trauma-exposed individuals, while reduced perceptions of hope and the use of avoidant coping strategies may place individuals at greater risk for depression following exposure to traumatic events.     

Emotional Processing Theory (EPT) and Exposure Therapy for PTSD

Emotional processing theory developed by E. B. Foa and M. J. Kozak (1986) has informed the conceptualization of anxiety disorders and the development of effective treatments for these disorders, including posttraumatic stress disorder (PTSD). This article presents a summary and update of emotional processing theory as it applies to the treatment of PTSD, data in support of this theory, and clinical examples of how the theory can be used to assist in the treatment of clients with PTSD. Common difficulties confronted during exposure therapy for PTSD, including underengagement and overengagement, are discussed in the context of emotional processing theory and suggestions for how to manage these difficulties are presented.     

Cognitive Behavioral Therapy for PTSD: The Role of Complex PTSD on Treatment Outcome

Posttraumatic stress disorder (PTSD) represents an often chronic and debilitating mental illness resulting from exposure to trauma. Although the most compelling evidence for the treatment of PTSD is cognitive behavioral therapy (CBT), many patients experience residual functional impairment, or relapse, suggesting that this approach does not work for all cases of PTSD. Repeated severe trauma, particularly during development, might increase the risk for a more intricate clinical profile, called complex PTSD (CPTSD), which might contribute to poorer treatment response. The following provides a comprehensive summary of the evidence examining whether CPTSD symptomatology is related to poorer treatment outcome of CBT, reviews the literature on the treatment of CPTSD, and offers insights into current issues and future directions of the construct.     

The Design and Evaluation of a Hope Enhancement Programme for Adults

The study evaluated the effectiveness of a hope enhancement programme for a group of adults and its impact on general psychological well-being. The intervention programme focused on participants' abilities to set feasible goals, planning ways to reach those goals (pathways) and increase determination and motivation (agency) to reach these goals. The workshop-format programme, consisted of six two-hour sessions conducted over five days. A pre and post-test design included an experimental group (n = 8), control group (n = 8) and ‘chat group’ (n = 8). Findings indicated that the programme increased hope levels of the experimental group as indicated by the Hope Scale and the Hopefulness Subscale of the Hunter Opinions and Personal Expectations Scale. Well-being also improved as indicated by a significant increase in sense of coherence along with a positive change in satisfaction with life. Recommendations for future research were made.     

A Case Study of Cognitive-Behavioral Conjoint Therapy for Combat-Related PTSD in a Same-Sex Military Couple

Military deployments to Iraq and Afghanistan are associated with increased risk for posttraumatic stress disorder (PTSD), depression, and relationship impairment. Unfortunately, the perceived stigma associated with seeking deployment-related behavioral health care in military settings has been a significant barrier to care. Historically, active-duty military service members involved in same-sex intimate relationships have experienced further stressors and barriers to care related to additional stigma and lack of social support. Prior federal regulations excluded sexual minorities from openly serving in the military, thereby limiting the available behavioral health services for same-sex couples. Since this ban was lifted after the repeal of the U.S. policy known as "Don’t Ask, Don’t Tell" in 2010, gay and lesbian service members have increased opportunities to obtain behavioral health care. One therapy that is newly available to sexual minority military couples is Cognitive-Behavioral Conjoint Therapy (CBCT), which effectively addresses co-occurring PTSD and relationship dysfunction. This case study illustrates the use of CBCT for the treatment of deployment-related PTSD in a same-sex active-duty military couple. After completing all 15 CBCT sessions, the couple reported clinically meaningful changes in the service member’s PTSD symptoms, which was maintained at the 2-month follow-up. The results of this case study indicate that CBCT for PTSD can have positive treatment outcomes with military same-sex couples. Further clinical implications are discussed.     

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.     

蓄意创伤受害者的创伤后应激障碍症状及影响因素分析

目的:研究蓄意创伤受害者的PTSD症状及影响因素。方法:采用事件冲击问卷、创伤经历揭露问卷、受害人认可问卷和攻击描述问卷等测查工具对163名蓄意创伤受害者进行调查。结果:(1)蓄意创伤受害者的PTSD三大症状之间相关显著,且方差分析结果差异显著,闯入性症状>回避症状>高警觉症状;(2)创伤严重程度与PTSD三大症状的相关显著;(3)创伤揭露中情绪反应对PTSD三大症状都有显著的预测作用;(4)社会认可度中的一般性排斥对PTSD三大症状都有显著的预测作用。结论:蓄意创伤受害者有着较强的PTSD症状,且以闯入性症状最为严重,回避和高警觉症状次之;创伤的严重程度、揭露时的情绪反应和社会认可度中的一般性排斥等都对蓄意创伤受害者的PTSD症状有影响作用。     

Competence in Delivering Cognitive Processing Therapy and the Therapeutic Alliance Both Predict PTSD Symptom Outcomes

Cognitive Processing Therapy (CPT) is efficacious in treating PTSD, but there remains a need to improve outcomes for individuals who do not fully respond to treatment. Differences between patient-therapist dyads in the fidelity (i.e., adherence and competence) of CPT delivery and the quality of the therapeutic relationship may partly explain differential levels of symptom improvement. Sessions were sampled from a randomized trial comparing different consultation conditions in training therapists new to CPT. Among 69 patients, one session from Sessions 1–3 and one session from Sessions 4–7 were reliably rated for adherence and competence using the CPT Therapist Adherence and Competence Scale, and for therapeutic alliance using the Working Alliance Inventory-Observer scale. Mixed models, including detrending using a fixed effect of session, predicted self-reported Posttraumatic Stress Disorder Checklist (PCL-IV) scores in one session using process scores from the previous session. The statistical interaction between fidelity and alliance scores to predict outcome was also examined. Alliance had significant, positive correlations (rs = 0.18–0.21) with same-session adherence and competence. Higher competence scores and higher therapeutic alliance scores in one session were independently associated with lower PCL-IV scores in the subsequent session. Adherence scores, which tended to be very high with relatively less variability, did not significantly relate to subsequent-session PCL-IV scores. Competence significantly interacted with alliance, such that sessions high in both competence and alliance predicted especially lower subsequent-session PCL-IV scores. A strong therapeutic alliance may have a synergistic, salutary effect with the competent delivery of CPT.     

A Review of Outcome Studies on Cognitive-Behavioral Therapy for Reducing Fear-Avoidance Beliefs Among Individuals With Chronic Pain

In the last two decades, emerging research has focused on advancing the explanations of how chronic pain becomes disabling. The fear-avoidance model of pain suggests that fear of reinjury in chronic pain patients leads to avoidance of certain movements that subsequently results in more pain and disability from that lack of movement. The literature supporting this model of pain and disability has allowed specific therapeutic interventions to be developed aimed at reducing pain-related fears in an attempt to reduce the physical symptoms and disability of chronic pain. Studies using cognitive-behavioral interventions to reduce fear-avoidance beliefs are reviewed and the treatments are evaluated based on the studies’ effectiveness. The author concludes that graded exposure in vivo appears to be the most effective treatment for chronic pain in individuals with increased fear and avoidance.     

Impact of Peer Support on PTSD,Hope, and Functional Impairment: A Mixed-Methods Study of Child Soldiers in Nepal

The experience of child soldiers during postwar civilian reintegration is recognized as a major contributor to mental health. For some children, postwar social relations may be more important than war trauma in determining psychosocial well-being. Mixed methods incorporating epidemiology and qualitative case studies were employed to evaluate the effects of family, peer, and community relations after reintegration on psychosocial outcomes: hope, functional impairment, and post-traumatic stress disorder (PTSD). Participants were 142 child soldiers, including 9 qualitative case studies. Peer support predicted increased hope, decreased functional impairment, and decreased PTSD symptoms. Conversely, problems with peer relations predicted less hope and more PTSD symptoms. Maximizing peer support and minimizing stigma from peers should be prioritized within psychosocial reintegration programs, especially among former child soldiers with PTSD.     

Differentiation of Self and Social Justice Commitment Mediated by Hope

This study tested a theoretical model of hope mediating the relationship between differentiation of self and social justice commitment among graduate students (N = 202) in the helping professions. The theory was based primarily on the social justice philosophies of Martin Luther King Jr., Cornel West, and Paulo Freire using a cultural psychology approach. Results generally supported the theoretical model. Implications are considered for both training and future research on social justice.     

Aquinas and the Virtues of Hope: Theological and Democratic

A prominent political historian has recently identified unwarranted optimism and unwarranted pessimism as democracy's “dual dangers.” While this historical analysis highlights the difficulties that accompany democratic hope, our prevailing conceptual vocabulary obscures the resources needed to address them. This essay attempts to recover these resources by excavating insights from Thomas Aquinas, who supplies one of the most systematic accounts of hope in the history of religious and political thought. By appropriating the conceptual structure of Thomas's theological virtue of hope, this essay reconstructs a democratic virtue that perfects acts of hoping in fellow citizens to achieve democratic goods and thereby enables citizens to respond properly to difficulties that tempt presumption and despair.     

Treating PTSD in Patients With Psychosis: A Within-Group Controlled Feasibility Study Examining the Efficacy and Safety of Evidence-Based PE and EMDR Protocols

The present study uses a within-group controlled design to examine the efficacy and safety of two psychological approaches to posttraumatic stress disorder (PTSD) in 10 patients with a concurrent psychotic disorder. Patients were randomly assigned either to prolonged exposure (PE; N = 5) or eye movement desensitization and reprocessing (EMDR; N = 5). Before, during, and after treatment, a total of 20 weekly assessments of PTSD symptoms, hallucinations, and delusions were carried out. Twelve weekly assessments of adverse events took place during the treatment phase. PTSD diagnosis, level of social functioning, psychosis-prone thinking, and general psychopathology were assessed pretreatment, posttreatment, and at three-month follow-up. Throughout the treatment, adverse events were monitored at each session. An intention-to-treat analysis of the 10 patients starting treatment showed that the PTSD treatment protocols of PE and EMDR significantly reduced PTSD symptom severity; PE and EMDR were equally effective and safe. Eight of the 10 patients completed the full intervention period. Seven of the 10 patients (70%) no longer met the diagnostic criteria for PTSD at follow-up. No serious adverse events occurred, nor did patients show any worsening of hallucinations, delusions, psychosis proneness, general psychopathology, or social functioning. The results of this feasibility trial suggest that PTSD patients with comorbid psychotic disorders benefit from trauma-focused treatment approaches such as PE and EMDR.     

Perceived Barriers and Preliminary PTSD Outcomes in an Open Pilot Trial of Written Exposure Therapy With Latinx Immigrants

Latinx immigrants experience substantial disparities in mental health treatment access, particularly for posttraumatic stress disorder (PTSD). The availability of brief, flexible interventions in Spanish may assist in reducing these disparities. Written Exposure Therapy (WET) is a five-session PTSD intervention that appears as effective as longer, gold-standard interventions, but has yet to be tested among Latinx immigrants. To test the acceptability and preliminary effectiveness of WET, 20 Spanish-speaking, Latinx immigrants conducted structured interviews at pretreatment, were offered WET, and completed posttreatment structured interviews. Open thematic coding of pre- and posttreatment interview questions examined perceived barriers and benefits of WET. Quantitative components examined symptom change across PTSD (PCL-IV-C) and depression (PHQ-9). Quantitative results indicated clinically meaningful and statistically significant change in PTSD symptoms using intent-to-treat analyses (M_diff = 17.06, SD_diff = 9.97, range = 0–29, t(15) = 6.84, p < .001). Open thematic coding identified four barrier-related themes and three benefit-related themes at pretreatment. At posttreatment, three barrier-related themes and two benefit-related themes were identified. Qualitative results largely suggested that perceived barriers were common to other PTSD interventions (e.g., exposure components). Only one participant identified barriers specific to WET. Results suggested WET may reduce PTSD symptoms among Latinx immigrants. WET also appeared to be acceptable and primarily viewed as beneficial among this population. WET is a promising intervention with Latinx immigrants and warrants further testing larger trials, including testing implementation strategies that may improve access to care.     

The acceptability and preference for the psychological treatment of PTSD

The acceptability and preference of psychological treatments is important in understanding patient treatment seeking, choice, engagement and attrition and possibly treatment response in health care. The acceptability of, and preference for, 14 different types of psychological treatment for posttraumatic stress disorder (PTSD) were investigated in a student population through invitation to participate in a web-based survey. Respondents were asked to rate each treatment on 10 scales and to rank the treatments in order of preference. Respondents were also asked whether they would seek treatment themselves, recommend treatment to friends and family, feel stigmatised by suffering from PTSD, had any prior knowledge of the treatments and if this had been positive or negative and whether they had a history of psychological problems or treatment. A total of 330 respondents completed the survey. A past or current history of psychological problems and treatment was surprisingly high. Almost all respondents indicated that they would seek or recommend treatment in spite of high levels of stigmatisation. Factor analysis of the 10 scales indicated two factors: Endorsement and Discomfort. Rank ordering on preference and Endorsement scores was highly consistent. The highly preferred and endorsed treatments involved cognitive therapy, exposure or psycho-education in spite of high levels of discomfort anticipated with exposure. Treatments involving new technologies, EMDR and psychodynamic psychotherapy received the lowest Endorsement and preference. There was a modest influence of prior knowledge of a treatment.     

PTSD symptoms and suicide ideation: Testing the conditional indirect effects of thwarted interpersonal needs and using substances to cope

Posttraumatic stress disorder (PTSD) symptoms and substance use have been associated with increased suicide ideation, but have rarely been examined within a larger theoretical context of suicide risk. The interpersonal theory of suicide posits that feeling disconnected from others (i.e., thwarted belongingness) and feeling like a burden on others (i.e., perceived burdensomeness) are associated with increased suicide ideation. We hypothesized that perceived burdensomeness and thwarted belongingness would mediate the relation between PTSD symptoms and suicide ideation, and that using substances to cope would moderate these relations. Participants were 254 college students reporting exposure to potentially traumatic experiences. Findings from a moderated mediation analysis indicated that perceived burdensomeness, but not thwarted belongingness, mediated the relation between PTSD symptoms and suicide ideation, and using substances to cope moderated this relation. Therapeutic interventions aimed at reducing suicide ideation might benefit from decreasing perceived burdensomeness and the use of substances to cope.     

灾后民众创伤后应激障碍（PTSD）与事件冲击量表（IES）的发展和应用

本文简单回顾了国际上在创伤后应激障碍研究中较常使用的自评测量工具——事件冲击量表（IES）及其修改版（IES-R）和儿童版CRIES的发展和应用。并综合报道了在四川绵竹运用IES-R对956名受灾群众进行的测查结果。推论,5·12汶川地震后,将有大约一半的幸存者在一到两个月出现PTSD的主要症状,并具有比较显著的性别差异：女性的分数普遍高于男性,建议及早进行心理危机干预。