Trauma Competency: An Active Ingredients Approach to Treating Posttraumatic Stress Disorder

Meta‐analytic studies have extracted 4 common elements among effective posttraumatic stress disorder treatments: cognitive restructuring and psychoeducation, a deliberate and continually improving therapeutic relationship, relaxation and self‐regulation, and exposure via narrative of traumatic experiences. The authors present a clinical treatment structure catalyzing these active ingredients into discrete therapeutic tasks that counselors can focus on to maximize treatment effectiveness. The 4 tasks represent an attempt to identify critical competencies and baseline standards for the field of trauma counseling.     

Meaning Made of Stress among Veterans Transitioning to College: Examining Unique Associations with Suicide Risk and Life‐Threatening Behavior

Meaning made of stress has been shown to be a unique predictor of mental and physical health. In this study, we examined the unique associations between two facets of meaning made of stress (comprehensibility and footing in the world) and suicide risk and life‐threatening behavior among military veterans who have transitioned to college were examined, controlling for demographic factors, religiousness, combat‐related physical injury, combat exposure, depressive symptoms, and posttraumatic stress symptoms. Findings suggest that comprehensibility (having “made sense” of a stressor) is uniquely associated with lower suicide risk and a lower likelihood of driving under the influence of drugs or alcohol and engaging in self‐mutilating behaviors.     

Meta‐Analysis of Counseling Outcomes for the Treatment of Posttraumatic Stress Disorder

This meta‐analysis of 152 published posttraumatic stress disorder (PTSD) clinical trials from 1990 to 2012 concluded that counseling generally produced a small to large effect of treatment across all comparison conditions at termination (d+ = 0.30 to 0.89). These gains were maintained at longest follow‐up (d+ = 0.58 to 0.86) for the wait‐list, treatment‐as‐usual, and single‐group comparisons, but not for the follow‐up placebo comparison (d+ = 0.15), probably because of the low power (j = 3 placebo studies). Clinical trial findings were synthesized using a random‐effects model. No effects of publication bias or moderating variables were evident. No difference was found between trauma‐focused and non‐trauma‐focused approaches. Implications for counseling practice and future PTSD outcome research are addressed.     

Treating Posttraumatic Stress Disorder in South Africa: An Integrative Model Grounded in Case-Based Research

The article presents a model for formulating and planning treatment for post-traumatic stress disorder (PTSD) in South Africa derived from the existing literature and in conjunction with a review of a series of studies of cases treated using the guidelines of Ehlers and Clark's cognitive therapy. It is argued that the construction of psychotherapies (or even components of psychotherapy) for PTSD in terms of traditional categories (“psychodynamic”, “cognitive-behavioural”, “narrative” etc.) is misleading and unhelpful. Instead, superordinate concepts derived from thinking about evidence-based practice provide a more grounded focus on the practical issues faced by therapists treating PTSD. These concepts, which include competences and metcacompetences, therapist responsiveness, stages of therapy and case formulation, provide a basis for a genuinely integrative approach. The proposed model suggests seven broad areas of clinical focus for work with PTSD which can be arranged at three levels of priority: level 1 crisis intervention and stabilization; level 2 promoting engagement with treatment, and level 3 selection, sequencing and timing of active treatment interventions. Material from the case series is used to illustrate the application of the model.     

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.     

Development of a Scale to Assess Posttraumatic Stress Disorder

This study presents a newly developed self-report Posttraumatic Stress Scale (PTSS) based on the DSM-IV (American Psychiatric Association, 1994). The scale assesses the trauma experienced by people via the specific criteria of reexperiencing, numbing and avoidance, hyperarousal, and functioning. The instrument was validated on 52 Vietnam veteran subjects diagnosed with posttraumatic stress disorder (PTSD), 64 subjects who were attending professional counseling for trauma-related incidents, and 176 subjects who had never been diagnosed with PTSD or had professional counseling. The test survey comprised the PTSS, Beck's Anxiety Inventory, Beck's Depression Inventory, Impact of Events Scale, the 12-item General Health Questionnaire, Inventory of Depressive Symptomatology, and Symptoms Checklist–90R. The test-retest reliability of the scale was assessed over a four- to six-week period. The scale had a high test-retest reliability and showed high convergent and concurrent validity. Construct validity as assessed through the comparison between the three groups was high; however, factor analysis revealed only two factors instead of the three factors assumed in the DSM-IV. Overall, the scale may be used by clinicians or clients.     

Meta‐Analysis of Trauma‐Focused Therapies for Treating the Symptoms of Posttraumatic Stress Disorder

This meta‐analysis of 46 between‐groups studies published between 1997 and 2015 detected treatment effects ranging from large to small when comparing trauma‐focused therapies with no treatment (g = ?1.05), supportive interventions (g = ?0.91), other interventions (g = ?0.57), and non‐trauma‐focused cognitive behavior therapies (g = ?0.08) for the treatment of posttraumatic stress disorder (PTSD). The independent random‐effects models detected modest publication bias and a negligible influence of moderating variables on treatment outcomes. Considerations for counselors who treat PTSD and suggestions for researchers are provided.     

Posttraumatic Stress Disorder and Emotion‐Focused Coping Among Disaster Mental Health Counselors

The authors surveyed 235 disaster mental health counselors (DMHCs) for levels of posttraumatic stress disorder (PTSD) symptom severity. A correlational design was used to examine the roles of adult attachment security, emotion regulation, and mindfulness in predicting PTSD symptoms among this group. Each of the 3 predictors was negatively correlated with PTSD symptom severity, and data supported a mediating role for emotion regulation. Results may inform DMHCs, other counselors, and individuals who train or deploy DMHCs.     

Exposure,Agency, Perceived Threat,and Guilt as Predictors of Posttraumatic Stress Disorder in Veterans

Using a sample of 289 Iraq/Afghanistan veterans, this study examined the contributions of combat exposure, agency, perceived threat, and guilt to posttraumatic stress disorder (PTSD) symptoms. Regression analyses indicated the four variables (together with demographic variables) accounted for 79% of the variance in PTSD symptoms. Guilt was the most important predictor. In addition, guilt mediated between exposure and PTSD symptoms, perceived threat and PTSD symptoms, and agency and PTSD symptoms. Implications of these findings are discussed.     

Effectiveness of Seeking Safety for Co‐Occurring Posttraumatic Stress Disorder and Substance Use

The authors evaluated the Seeking Safety program's effectiveness for treating posttraumatic stress disorder (PTSD) and substance use symptoms across 12 between‐groups studies (N = 1,997 participants). Separate meta‐analytic procedures for studies implementing wait list/no treatment (n = 1,042) or alternative treatments (n = 1,801) yielded medium effect sizes for Seeking Safety for decreasing symptoms of PTSD and modest effects for decreasing symptoms of substance use. Limitations of the findings and implications for counselors are discussed.     

Partners’ Attributions for Service Members’ Symptoms of Combat-Related Posttraumatic Stress Disorder

The association of service members’ combat-related PTSD with partners’ distress is weaker when spouses/partners believe that service members experienced more traumatic events during deployment. Also, when simultaneously examining partners’ perceptions of all PTSD symptoms, perceptions of reexperiencing symptoms (the symptoms most obviously connected to traumatic events) are significantly negatively related to distress in partners. These findings are consistent with the notion that partners may be less distressed if they make external, rather than internal, attributions for service members’ symptoms. The present study explicitly tests this possibility. Civilian wives of active duty service members completed measures regarding their own marital satisfaction, their perceptions of service members’ combat exposure during deployments, their perceptions of service members’ symptoms of PTSD, and their attributions for those symptoms. External attributions were significantly positively associated with perceptions of combat exposure (r_p = .31) and reexperiencing symptoms (β = .33) and significantly negatively associated with perceptions of numbing/withdrawal symptoms (r_p = –.22). In contrast, internal attributions were significantly negatively associated with perceptions of reexperiencing symptoms (β = –.18) and significantly positively associated with perceptions of numbing/withdrawal symptoms (β = .46). Internal attributions significantly moderated the negative association of PTSD symptoms with marital satisfaction, such that the association strengthened as internal attributions increased. These findings are the first explicit support for an attributional understanding of distress in partners of combat veterans. Interventions that alter partners’ attributions may improve marital functioning.     

Posttraumatic Stress Following Acute Medical Trauma in Children: A Proposed Model of Bio-Psycho-Social Processes During the Peri-Trauma Period

Millions of children worldwide experience acute medical events. Children’s responses to these events range from transient distress to significant posttraumatic stress disorder symptoms (PTSS). While many models suggest explanations for the development and maintenance of PTSS in adults, very few have focused on children. Current models of child PTSS are primarily restricted to the post-trauma period, thus neglecting the critical peri-trauma period when screening and preventive interventions may be most easily implemented. Research on PTSS in response to pediatric medical trauma typically examines predictors in isolation, often overlooking potentially important interactions. This paper proposes a new model utilizing the bio-psycho-social framework and focusing on peri-trauma processes of acute medical events. Understanding the relationships among bio-psycho-social factors during peri-trauma can inform early identification of at-risk children, preventive interventions and clinical care. Recommendations for future research, including the need to examine PTSS in the context of multiple influences, are discussed.     

Narrative Therapy to Prevent Illness‐Related Stress Disorder

More than 94% of cancer patients described the experience as the most traumatic event they have ever faced and 13% have posttraumatic stress disorder (PTSD) in the aftermath. Empirical evidence demonstrates that certain behaviors lead to more positive health outcomes. Although many patients automatically engage in these behaviors, many others do not. Treatments typically focus on short‐term, symptom‐focused strategies. Narrative‐Expressive Therapy is an intervention designed to address the long‐term, underlying stress and to prevent PTSD in patients with serious illness.     

The Relationship of Offense-Specific Forgiveness to Posttraumatic Stress Disorder Symptoms in College Students

The relationship between offense-specific forgiveness and post-traumatic stress disorder (PTSD) symptoms was examined in a cross-sectional survey of 178 college students reporting interpersonal trauma exposure, that is, a trauma exposure in which they identified a specific perpetrator. Higher levels of offense-specific forgiveness were significantly related to lower levels of PTSD symptoms. In path analyses, however, when gender and offense severity were allowed to directly predict both forgiveness and PTSD symptoms, the relationship was reduced to marginal significance. Exploratory analyses revealed that within the five most-commonly endorsed trauma subtypes, the relationship between forgiveness and PTSD symptoms may differ in strength and direction as a function of trauma type. Implications for research and treatment are discussed.     

The Relationship Between a Hierarchical Transdiagnostic Model of Vulnerability Factors and Posttraumatic Stress Disorder Symptom Clusters

The latent structure of Post-Traumatic Stress Disorder (PTSD) symptomology is the subject of ongoing deliberation. The cognitive vulnerabilities of Negative Affect, Anxiety Sensitivity and Intolerance of Uncertainty have been shown to explain symptoms clusters in multiple anxiety and mood disorders, and may be able to offer further insight to explain PTSD symptomology. Using structural equation modelling, this study examines whether a hierarchical model consisting of the general cognitive factor of Negative Affect and the transdiagnostic risk factors of Anxiety Sensitivity and Intolerance of Uncertainty can explain variability among PTSD symptom clusters as defined by the DSM-5 and/or Dysphoria models of PTSD. Anxiety Sensitivity and Intolerance of Uncertainty were tested as mid-level factors between Negative Affect and the PTSD symptom constructs. The hierarchical model fit the data well in both the DSM-5 and Dysphoria models. Negative Affect consistently showed significant direct effects on each symptoms cluster in both models. Anxiety Sensitivity served as a significant mediator of Negative Affect for several symptom clusters in both models. Intolerance of Uncertainty was non-significant either as a direct effect or as a mediator of Negative Affect in all analyses. This study demonstrates how the hierarchical model of Negative Affect, Anxiety Sensitivity and Intolerance of Uncertainty may fit upon multiple PTSD symptom constructs and offers new directions for conceptualizing this disorder.

     

An in-Vivo Daily Self-Report Approach to the Assessment of Outcomes of Two Psychotherapies for Women With Posttraumatic Stress Disorder

Emotion regulation and interpersonal psychotherapies that do not require trauma memory processing have been shown to be effective in treating posttraumatic stress disorder (PTSD). This study used a novel method to assess in vivo outcomes in a randomized clinical trial with women (N = 147; ages 18–54; 61% of color; 94% low income) with full (79%) or partial (21%) PTSD. Participants were assigned to affect regulation or interpersonal therapy, or wait-list, and completed daily self-reports for 2 to 4 weeks at baseline and up to 30 days at posttest. Mixed model regression analyses tested pre-post change on five factor analytically derived aggregated daily self-report scores. Emotion regulation-focused therapy was associated with reduced PTSD symptoms, dysregulation, and negative affect, and improvement in adaptive self-regulation and positive affect. Interpersonal-focused therapy was associated with reduced PTSD symptoms and dysregulation. Although both therapies were associated with reduced PTSD symptoms, whether this was due to nonspecific factors rather than the treatments per se could not be determined. Daily self-report data warrant further investigation in psychotherapy research with disorders such as PTSD, in order to assess affective and interpersonal dysregulation and adaptive regulation as they occur in daily life.     

Alternative Explanations of Emotional Numbing of Posttraumatic Stress Disorder: An Examination of Hyperarousal and Experiential Avoidance

The mechanisms that underlie the emotional numbing symptoms associated with PTSD are not well understood. Studies of Vietnam combat veterans have demonstrated that hyperarousal symptoms predict emotional numbing symptoms more strongly than do other symptoms of PTSD. This study sought to extend these findings through the self-report of 170 female sexual assault survivors. The study also examined whether the relationship between hyperarousal and emotional numbing symptoms was the result of the relationship of each of these to another variable, the tendency to engage in experiential avoidance. Results were consistent with and extended previous findings. Hyperarousal symptoms were also found to predict emotional numbing symptoms above and beyond experiential avoidance, as well as all other symptoms of PTSD.     

Symptoms of Posttraumatic Stress Disorder and Social Support Among Children and Adolescents After the 2010 Haitian Earthquake

This study explored the prevalence of posttraumatic stress disorder (PTSD) symptoms related to social support received by the children and adolescents who survived the earthquake on January 12, 2010, in Haiti. A strategy of stratified sampling was used, and 540 children and teenagers were questioned. Questionnaires based on the PTSD Checklist, the Impact of Event Scale-Revised, and the Peritraumatic Distress Inventory, among others, were used and bivariate statistical analyses were carried out. The results showed high rates of complete and partial PTSD symptoms, with higher rates among females, and indicated the need for reinforcing social support as a resilience factor for youth.     

Management of Post-Traumatic Stress Disorder in the Military: An Intervention Model

Military Forces are involved in combat, peacekeeping operations and disaster management. The nature of such operations include violent conflict, death of women and children, child soldiers and own forces. These traumatic circumstances can contribute to the development of post traumatic stress disorder (PTSD) in members involved. This article discusses the role and function of psychological debriefing for trauma with operational military units. It also proposes a preliminary intervention model to manage PTSD in military forces.     

Accuracy and Bias in Perceptions of Spouses' Life‐Sustaining Medical Treatment Preferences1

This research investigated accuracy, projection bias, and base‐rate utilization in spouses' perceptions of end‐stage renal disease patients' preferences for life‐sustaining medical treatment in hypothetical conditions of declining health. Multilevel models revealed that spouses' perceptions were largely biased, determined by their own preferences for the patients' treatment (projection bias) and by typical treatment preferences (base‐rate utilization). Both biases, however, served as indirect routes to a modest degree of accuracy. Moreover, spouses who overestimated patients' preferences for life‐sustaining treatment and who perceived patients' preferences as consistent with their own reported higher levels of marital adjustment than did those who were less biased. Results suggest that spouses' biases in judgments of patients' treatment preferences may promote accuracy and marital adjustment functionally.