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.     

A preliminary examination of the role of psychotherapist fidelity on outcomes of cognitive processing therapy during an RCT for military sexual trauma-related PTSD

While cognitive processing therapy (CPT) is an effective evidence-based treatment for many veterans with military-related post-traumatic stress disorder (PTSD), not all veterans experience therapeutic benefit. To account for the discrepancy in outcomes, researchers have investigated patient- and research design-related factors; however, therapist factors (e.g. fidelity) have received less attention. The present study is a preliminary examination of the effect of psychotherapists’ fidelity during CPT on clinical outcomes during a randomized clinical trial (RCT) for military sexual trauma-related PTSD. PTSD symptoms, trauma-related negative cognitions (NCs), and depression symptoms were assessed for 72 participants at baseline, and 1-week, 2-month, 4-month, and 6-month posttreatment. Of the four CPT therapists, two were found to have significantly poorer (i.e. “below average”) treatment fidelity scores compared to the other two therapists who had “good” treatment fidelity scores. To examine possible therapist effects on outcomes, hierarchical linear modeling was utilized with therapist fidelity entered as a Level 2 predictor. Participants treated by a therapist with “good” treatment fidelity experienced significantly greater reductions in PTSD symptoms, NCs, and depression symptoms than patients treated by a therapist with “below average” treatment fidelity. Our preliminary findings highlight the importance of monitoring, maintaining, and reporting fidelity in psychotherapy treatment RCTs.     

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.     

Anxiety Sensitivity and Interoceptive Exposure: A Transdiagnostic Construct and Change Strategy

Recent findings support the relevance of anxiety sensitivity (AS) and interoceptive exposure (IE) across emotional disorders. This study (a) evaluated levels of AS across different anxiety disorders, (b) examined change in AS over the course of transdiagnostic psychological intervention, and its relationship with outcome, and (c) described the implementation of IE to address AS with patients with different anxiety disorders. Participants (N = 54) were patients who received treatment with the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) in two consecutive treatment trials. Participants completed a measure of AS at pre- and posttreatment, and multiple occasions during treatment. Symptom severity was assessed at pre- and posttreatment, and clinical information related to physical symptoms and IE were collected as part of routine clinical practice. Elevated AS was observed at pretreatment across diagnoses and decreases in AS were observed from pre- to posttreatment. Similar changes occurred across the diagnostic categories, notably coinciding with the introduction of IE. Change in AS was correlated with reduced symptom levels at posttreatment and 6-month follow-up. Patients with different anxiety disorders endorsed similar physical symptoms and practiced similar IE exercises with similar effects. Results provide preliminary support for the usefulness of IE as a treatment strategy across the spectrum of anxiety disorders, and additional support for the transdiagnostic relevance of AS.     

Exposure Therapy for Posttraumatic Stress Disorder: A Meta-Analysis

This meta-analysis compares the findings of empirical studies that employ either a traditional form of cognitive–behavioral-based exposure therapy or virtual reality exposure therapy (VRET) for the treatment of posttraumatic stress disorder (PTSD) to determine which is more viable and effective. Statistical analyses were performed on 26 studies to determine pre- to posttreatment effect sizes and interactions. Results demonstrated a trend toward significance in favor of traditional exposure therapy showing lower posttreatment PTSD. Limitations included a restricted number of relevant studies; future research on VRET for PTSD should orient more to experimental designs, larger samples, and increased use of control groups.     

Using Explicit Case Formulation to Improve Cognitive Processing Therapy for PTSD

We investigated the utility of explicit case formulation (CF) within Cognitive Processing Therapy (CPT) for individuals with posttraumatic stress disorder (PTSD). An uncontrolled pre-posttreatment design was used. Participants attended 12–16 weekly sessions of CPT with explicit CF, where CF guided treatment length and treatment components. Treatment was completed by 19 of the 23 participants who started therapy. Results revealed significant reductions in PTSD and depression severity as well as unhelpful PTSD-related beliefs from pre- to posttreatment (ds between 1.10 – 1.92) and treatment gains were maintained at 3-month follow-up. Of the participants available at posttreatment for assessment, 69% (n = 11/16) met good end-state functioning for PTSD and 62% (n = 8/13) did so at follow-up. Finally, 72% (n = 13/18) of those interviewed at posttreatment no longer met criteria for PTSD and this was found for 93% of those assessed at follow-up (n = 14/15). Treatment, and CF in particular, was found to be acceptable by participants. Explicit case formulation did not interfere with positive outcomes of Cognitive Processing Therapy for PTSD. Further clinical implications and future directions for research are discussed.     

Isolating the Effects of Mindfulness Training Across Anxiety Disorder Diagnoses in the Unified Protocol

The Unified Protocol for Transdiagnostic Treatment (UP; Barlow et al., 2011) has recently demonstrated statistically equivalent therapeutic effects compared to leading cognitive behavioral therapy (CBT) protocols for anxiety disorders designed to address disorder-specific symptoms (i.e., single-disorder protocols [SDP]); Barlow et al., 2017). Although all treatment protocols included similar evidence-based CBT elements, investigation of those related to symptom improvement in the UP is warranted. Because the UP is unique from the SDPs for its inclusion of mindfulness, the present study evaluated mindfulness as a primary treatment element. We explored whether UP participants, compared to SDP, demonstrated greater improvements in mindfulness from pre- to posttreatment, and whether these improvements predicted posttreatment severity across anxiety disorder diagnoses. Participants were individuals with a principle anxiety disorder (N = 179) randomized to receive either the UP or SDP. Results indicated significant improvements pre- to posttreatment in mindfulness for participants receiving either the UP or SDP. However, at posttreatment, mindfulness scores were significantly greater for the UP condition. At the diagnosis level, posttreatment scores in mindfulness were significantly greater in the UP condition than the respective SDP conditions for principal Generalized Anxiety Disorder (GAD) and Social Anxiety Disorder (SOC). Moreover, results suggest that change in mindfulness is related to posttreatment severity, when moderated by treatment condition, but only for participants with principal GAD. Taken together, the UP is effective in improving mindfulness in a sample with heterogeneous anxiety disorders, but this change seems particularly relevant for reduction in symptom severity for individuals with principal GAD.     

The effectiveness of cognitive behavioral therapy for generalized anxiety disorder in a frontline service setting

The goal of the current study was to test the generalizability of cognitive behavioral therapy (CBT) for generalized anxiety disorder (GAD) in a frontline service setting. Twenty-nine patients who presented to treatment clinics with problematic worry were provided CBT for GAD. Among the intent-to-treat sample, there were no significant changes in worry or depression from pre- to posttreatment. Treatment completers showed significant pre- to posttreatment reductions on measures of worry and depression. The magnitude of change was smaller than has been reported in randomized control trials (RCTs). Although the frontline service setting differed from RCT settings in multiple ways, treatment completers nonetheless achieved moderate to large decreases in self-reported worry and depression.     

Does Exposure and Response Prevention Behaviorally Activate Patients With Obsessive-Compulsive Disorder? A Preliminary Test

Exposure and response prevention (ERP) and behavioral activation (BA) are effective treatments for obsessive-compulsive disorder (OCD) and depression, respectively. Patients with OCD often exhibit depression; furthermore, ERP for OCD is associated with reduced depressive symptoms. To our knowledge, no study has examined whether ERP itself functions to behaviorally activate patients with concurrent OCD and depressive symptoms. This prospective study was designed to test the hypotheses that (a) OCD exposure hierarchy completion, increased BA, and depressive symptom reduction would all be related, and (b) pre- to posttreatment changes in BA would mediate the direct effect of OCD hierarchy completion on posttreatment depressive symptoms, even after controlling for pretreatment depressive symptoms, pretreatment BA, pre- to posttreatment reductions in OCD symptoms, treatment duration, and antidepressant medication use. Patients (N = 90) with a primary diagnosis of OCD who received residential ERP for OCD completed a self-report battery at pre- and posttreatment. Exposure hierarchy completion, increases in BA, and decreases in depression were all significantly correlated (rs ranged .33 to .44). The effect of hierarchy completion on posttreatment depressive symptoms was fully mediated by pre- to posttreatment changes in BA. Findings highlight the potential for ERP to exert antidepressant effects by behaviorally activating patients. Limitations, clinical implications, and future directions are discussed.     

Cognitive Processing Therapy Delivered in 5 Days via Telehealth to a Gay Latino Adolescent: A Clinical Case Study

Cognitive Processing Therapy (CPT) has been thoroughly investigated as an efficacious treatment for posttraumatic stress disorder (PTSD). However, for many, the barriers to receiving treatment in the traditional weekly, in-person format prevent engagement. Recent evidence suggests alternative modalities, such as telehealth, and condensed administration of treatment protocols may reduce barriers, increasing treatment completion. This case study reports the treatment of a gay-identifying adolescent Latino male who received 10 sessions of CPT over the course of 5 consecutive days (CPT-5). The patient experienced significant reduction in PTSD symptoms over the course of treatment, dropping below the clinical threshold for PTSD diagnosis by the 10th session. Treatment gains were maintained, and continued, 6 weeks posttreatment. Further, the patient reported marked reduction in suicidality and substance use. In conclusion, the administration of CPT-5 via telehealth holds promise as an effective evidence-based treatment for adolescents with PTSD, including those holding multiple historically marginalized identities, though further investigation through clinical trials is warranted.     

Improving Delivery Behaviors During Exposure for Pediatric OCD: A Multiple Baseline Training Trial With Community Therapists

This study tested whether a new training tool, the Exposure Guide (EG), improved in-session therapist behaviors (i.e., indicators of quality) that have been associated with youth outcomes in prior clinical trials of exposure therapy. Six therapists at a community mental health agency (CMHA) provided exposure therapy for 8 youth with obsessive–compulsive disorder (OCD). Using a nonconcurrent multiple baseline design with random assignment to baseline lengths of 6 to 16 weeks, therapists received gold-standard exposure therapy training with weekly consultation (baseline phase) followed by addition of EG training and feedback (intervention phase). The primary outcome was therapist behavior during in-session exposures, observed weekly using a validated coding system. Therapist behavior was evaluated in relation to a priori benchmarks derived from clinical trials. Additional outcomes included training feasibility/acceptability, therapist response to case vignettes and beliefs about exposure, and independent evaluator-rated clinical outcomes. Three therapists reached behavior benchmarks only during the EG (intervention) phase. Two therapists met benchmarks during the baseline phase; one of these subsequently moved away from benchmarks but met them again after starting the EG phase. Across all therapists, the percentage of weeks meeting benchmarks was significantly higher during the EG phase (86.4%) vs. the baseline phase (53.2%). Youth participants experienced significant improvement in OCD symptoms and global illness severity from pre- to posttreatment. Results provide initial evidence that adding the EG to gold-standard training can change in-session therapist behaviors in a CMHA setting.     

Méta-analyse et efficacité des psychothérapies : faits et fictions

In a political environment increasingly concerned with the problem of escalating health care costs, the issue of psychotherapy efficacy evaluation is still debated. Historically, this debate started after Eysenck (1952) published a famous article suggesting that average improvement from pre- to post-therapy has nothing to do with psychotherapy participation, but something that would tend to happen anyway (“spontaneous remission”). Wanting to prove that psychotherapy was effective (Glass, 2000), Smith and Glass (1977) published the first meta-analysis of the psychotherapy efficacy, combining the results of several controlled clinical trials, and found that psychotherapy was remarkably efficacious. Following a brief historical introduction, the objectives of this paper is to define the principles of meta-analysis, to discuss of epistemological contextualization of this methodological approach, and finally to examine the interest and limits of the application of this method in the field of evaluation of psychotherapy.     

Family Focused Treatment for Patients with Bipolar Disorder in Turkey: A Case Series

Family-focused therapy (FFT) is a 9-month, 21-session structured psychoeducational treatment for bipolar disorder. Several US-based studies have documented its efficacy as adjunctive to medication for depression stabilization and relapse prevention. However, FFT has never been applied outside of the United States. The objective of this case series is to explore the applicability of FFT in a non-Western culture. Ten patients with bipolar disorder and their family members attended the 9-month FFT as adjunctive to pharmacotherapy in an outpatient specialty clinic in Izmir, Turkey. Patients improved in Global Assessment of Functioning Scores and Clinical Global Impression Scores from pre- to posttreatment. Case studies are given, which illustrate the differences between Western and non-Western families coping with bipolar disorder. FFT was easily applied to a Turkish sample with few changes in format or focus. Adaptations included substitution of oral for written therapeutic tasks or homework assignments. Randomized controlled trials are needed to test the clinical effectiveness of FFT and other psychosocial interventions in non-Western cultures.     

A meta-analysis of subjective well-being interventions among elders

This meta-analysis demonstrated that interventions have a significant (p less than .05) immediate posttreatment influence on elders' subjective well-being but that their beneficial effect dissipates within 1 month. For 28 effect sizes derived from immediate posttreatment occasions (delay = 0 days), the median value was 0.67. Immediate posttreatment effect sizes for control enhancement (M = 1.12), psychoeducational (M = 0.70), and social activity (M = 0.66) treatments were significantly (p less than .05) above zero and not significantly different from each other. In contrast, for 17 effect sizes derived from delayed posttest occasions (delay greater than 0 days), the median value was 0.07. For effect sizes extracted from studies with both an immediate and a delayed posttest, the mean decrease over a 30-day period was 1.02.     

Of mice and marbles: Novel perspectives on burying behavior as a screening test for psychiatric illness

Burying forms part of the normal behavioral routine of rodents, although its expression is species-specific. However, it has been suggested that aberrant burying behavior, of which marble-burying (MB) is an example, may represent neophobic and/or compulsive-like behavior. In the present investigation, we assessed MB in an established animal model of obsessive–compulsive disorder (OCD)—namely, spontaneous stereotypy in the deer mouse—to establish whether high (H) stereotypy is associated with neophobia and/or another compulsive endophenotype, i.e. MB, as compared to nonstereotypical (N) controls. A three-trial, one-zone MB test was performed over three consecutive evenings both before and after chronic treatment with high-dose (50 mg/kg/day) oral escitalopram. Neophobia was measured via the number of marbles buried during the first pre- and posttreatment MB trials, and compulsive-like behavior via the number of marbles buried over all pre- and posttreatment MB trials. The data from the present study support earlier findings that burying is a normal behavioral routine (inherent burying behavior, IBB) that is expressed by all deer mice, irrespective of stereotypical cohort, and is not associated with either neophobia or compulsiveness. Indeed, chronic escitalopram treatment, which is similarly effective in treating clinical anxiety and OCD, as well as in attenuating H behavior, failed to influence IBB. Although 11 % of the animals presented with a unique burying endophenotype (high burying behavior), escitalopram also failed to attenuate said behavior, necessitating further investigation as to its relevance. In conclusion, MB cannot be regarded as a measure of anxiety-like or compulsive behavior in the deer mouse model of OCD.     

Acceptance and Commitment Therapy for Anxiety Disorders: Three Case Studies Exemplifying a Unified Treatment Protocol

Acceptance and Commitment Therapy (ACT) is an innovative acceptance-based behavior therapy that has been applied broadly and successfully to treat a variety of clinical problems, including the anxiety disorders. Throughout treatment ACT balances acceptance and mindfulness processes with commitment and behavior change processes. As applied to anxiety disorders, ACT seeks to undermine excessive struggle with anxiety and experiential avoidance––attempts to down-regulate and control unwanted private events (thoughts, images, bodily sensations). The goal is to foster more flexible and mindful ways of relating to anxiety so individuals can pursue life goals important to them. This article describes in some detail a unified ACT protocol that can be adapted for use with persons presenting with any of the major anxiety disorders. To exemplify this approach, we present pre- and posttreatment data from three individuals with different anxiety disorders who underwent treatment over a 12-week period. The results showed positive pre- to posttreatment changes in ACT-relevant process measures (e.g., reductions in experiential avoidance, increases in acceptance and mindfulness skills), increases in quality of life, as well as significant reductions in traditional anxiety and distress measures. All three clients reported maintaining or improving on their posttreatment level of functioning.     

Change in sleep symptoms across Cognitive Processing Therapy and Prolonged Exposure: A longitudinal perspective

Sleep disturbance is a core component in posttraumatic stress disorder (PTSD). Although cognitive-behavioral treatments for PTSD reduce the severity of sleep symptoms, they do not lead to complete remission. The present study examines the impact of Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) on subjective measures of sleep disturbance from treatment randomization through long-term follow-up (LTFU). Participants were 171 female rape victims with PTSD who were randomly assigned to CPT, PE, or Minimal Attention (MA). After 6-weeks, the MA group was randomized to CPT or PE. Sleep symptoms were assessed at baseline, post-MA, post-treatment, 3-months, 9-months and LTFU using the Pittsburgh Sleep Quality Index (PSQI) and nightmare and insomnia items from the Clinician Administered PTSD Scale. Change in sleep during MA, from pre- to post-treatment for CPT and PE, and from post-treatment through LTFU was assessed using piecewise hierarchical linear modeling with the intent-to-treat sample. Controlling for medication, sleep improved during CPT and PE compared to MA, and treatment gains were maintained through LTFU. CPT and PE were equally efficacious and improvements persist over LTFU, yet, neither produced remission of sleep disturbance. Overall, sleep symptoms do not remit and may warrant sleep-specific treatments.     

The Findings of a Cochrane Meta-Analysis of Couple Therapy in Adult Depression: Implications for Research and Clinical Practice

The association between depressive symptoms and distressed intimate relationships supported the assumption that couple therapy, by focusing on the interpersonal context of depression, might be more effective as a treatment for depression than individual psychotherapy or drug therapy. This issue was addressed by a Cochrane meta-analysis assessing the evidence from clinical trials of couple therapy for depression in comparison with individual psychotherapy, drug therapy, and no/minimal intervention, including fourteen studies with 651 participants. No study was found free of bias and the quality of the evidence was low, with major problems of small sample sizes, missing outcome data, selective reporting, lack of information on random sequence generation and allocation concealment, recruitment of people not representative of clinical practice, and allegiance bias. The meta-analysis showed that both couple therapy and individual psychotherapy improved depressive symptoms at end of treatment and after 6 months or longer, with moderate effect sizes, without any difference between the two treatments. Couple therapy was more effective in reducing couple distress. This effect was larger in studies with distressed couples only and should be considered as relevant in its own right. Couple therapy is a viable option for the treatment of a depressed partner, especially in discordant couples. Future research should address several issues left open to provide a sound empirical foundation for clinical practice.     

Cognitive Behavioral Therapy for Social Anxiety Disorder: Predictors of Treatment Outcome in a Quasi-Naturalistic Setting

We examined the outcomes of individual cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) in a sample of 93 adults seeking treatment in a university outpatient clinic specializing in CBT for SAD. Treatment followed the structure of a manual, but number of sessions varied according to client needs. After approximately 20 weeks of therapy, patients’ social anxiety had decreased and their quality of life had increased. Patients with more severe SAD or comorbid major depressive disorder (MDD) at pretreatment demonstrated higher levels of social anxiety averaged across pre- and posttreatment. However, clinician-rated severity of SAD, comorbid MDD, or comorbid generalized anxiety disorder did not predict treatment outcome. Higher pretreatment scores on measures of safety behaviors and cognitive distortions were associated with higher social anxiety averaged across pre- and posttreatment and predicted greater decreases from pre- to posttreatment on multiple social anxiety outcome measures. We found no predictors of change in quality of life. Those with high levels of safety behaviors and distorted cognitions may benefit more from CBT, perhaps due to its emphasis on targeting avoidance through exposure and changing distorted thinking patterns through cognitive restructuring methods. Our study lends support to the body of research suggesting that manualized CBT interventions can be applied flexibly in clinical settings with promising outcomes for patients over a relatively short course of therapy.