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.     

Subjective Sleep Disturbances in Sexual Assault Survivors: Associations With Trauma and Posttraumatic Stress Disorder Symptom Severity

Prior work implicates sleep disturbance in the development and maintenance of posttraumatic stress disorder (PTSD). However, the majority of this literature has focused on combat veteran men, and limited work has examined links between sleep disturbance and PTSD symptoms in sexual assault survivors. This is a notable gap in the literature, as sexual trauma is disproportionately likely to result in PTSD and is more common in women. We sought to examine the relations between subjective sleep disturbance, sexual assault severity, and PTSD symptoms in a sample of sexual assault survivors with PTSD (PTSD+), without PTSD (PTSD-), and healthy controls. The sample (N = 60) completed the Insomnia Severity Index and prospectively monitored their sleep for 1 week using the Consensus Sleep Diary. The sexual assault survivors also completed the Sexual Experiences Survey and PTSD Checklist-5. Results of group comparisons found that the PTSD+ group reported significantly higher insomnia symptoms, longer sleep onset latency, more nocturnal awakenings, and lower sleep quality compared to the healthy control group and higher insomnia symptoms compared to the PTSD- group. Results of regression analyses in the sexual assault survivors found that insomnia symptoms and number of nocturnal awakenings were significantly associated with higher PTSD symptoms, and sexual assault severity was significantly associated with higher insomnia symptoms, longer sleep onset latency, and lower sleep quality. These findings highlight specific features of sleep disturbance that are linked to trauma and PTSD symptom severity among sexual assault survivors.     

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.     

Mediators of Posttraumatic Mental Health in Sexual Assault Survivors

The development of posttraumatic growth (PTG) and the relationship between PTG and distress outcomes in sexual assault is an important area of investigation. Recent research suggests that some forms of cognitive processing might be critical in the development, maintenance, and resolution of posttraumatic mental health among sexual assault survivors. The objective of this study was to examine factors associated with posttraumatic mental health among sexual assault survivors. Seventy-three participants who experienced sexual assault completed measures of trauma symptoms, PTG, changes in outlook, cognitive processing, and support and coping. Results revealed that significant levels of posttraumatic symptomatology and low levels of PTG were reported 3 years following sexual assault. A weak relationship was found between symptoms of distress and growth. Contrary to predictions, only ratings of hope and brooding rumination were mediators of the relationship between posttraumatic symptoms and PTG. Reflective rumination was not related to the development of PTG.     

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.     

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.     

Temporal Relationship Between Change in Subjective Distress and PTSD Symptom Decrease During Prolonged Exposure Therapy for Posttraumatic Stress Disorder

There is growing evidence that change in distress is an indicator of change during Prolonged Exposure (PE) for posttraumatic stress disorder (PTSD). However, temporal sequencing studies investigating whether change in distress precedes PTSD symptom decline are lacking. These studies are essential since the timeline between indicators of change and treatment outcome is a key assumption for mediation. The aim of the present study was to assess the temporal relationship between within- and between-session change in subjective distress and PTSD symptom decrease. We analyzed session data from 86 patients with PTSD. Data were analyzed using dynamic panel models. We distinguished temporal effects (within-persons) from averaged effects (between-persons). Results regarding the temporal effect showed that within-session change in subjective distress preceded PTSD symptom improvement while the reversed effect was absent. Averaged within-session change in subjective distress was also related to PTSD symptom improvement. Results regarding the temporal effect of between-session change in subjective distress showed that it did not precede PTSD symptom improvement. Averaged between-session change in subjective distress was related to PTSD symptom improvement. This study provides evidence for within- but not between-session change in subjective distress as indicator of change during PE. We also found that the way of modeling potential indicators of change affects results and implications. We recommend future studies to analyze mediators during treatment using temporal rather than averaged effects.     

Cortisol Response Following Exposure Treatment for PTSD in Rape Victims

This study examined changes in salivary cortisol levels pre- to posttreatment in adult female rape victims diagnosed with posttraumatic stress disorder (PTSD) randomly assigned to be treated with either prolonged exposure therapy or eye movement desensitization and reprocessing. Salivary cortisol was collected at baseline, Session 3, and Session 9. A significant decrease in salivary cortisol levels was observed in individuals classified as treatment responders in both treatment conditions. Findings suggest that successful exposure-based treatments for PTSD that result in trauma-related and depressive symptom reduction may impact the action of the hypothalamic–pituitary–adrenal axis as measured by changes in level of salivary cortisol from pre- to posttreatment.     

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.     

The Temporal Relations of PTSD Symptoms Among Treatment-Seeking Victims of Sexual Assault: A Longitudinal Study

This prospective study assessed the temporal relationships between the symptom clusters of PTSD in two nonprobability samples of treatment-seeking victims of sexual abuse: rape victims and adult survivors of childhood sexual abuse. Both groups were assessed at three time periods using self-report measures of PTSD symptomology. Findings from two cross-lagged panel analyses indicated weak temporal relationships between the symptom clusters of PTSD; however, avoidance and emotional numbing symptoms were found to exert the strongest cross-lagged effects. Avoidance and emotional numbing symptoms were also found to be the strongest predictor of subsequently meeting caseness for PTSD in both samples. Results suggest that there are minimal cross-lagged effects between the PTSD symptom clusters after three months from traumatic exposure.     

Ethics in College Sexual Assault Research

The persistently high rates of sexual assault on college campuses have led to an increasing demand for a solution to the problem. In response, research in the field is growing rapidly. With any expanding field, proper focus needs to be given to ethical dilemmas that may arise when studying a sensitive topic. College students who have experienced a sexual assault are a highly vulnerable population. As the current literature is limited, this article considers the ethical implications of conducting research with college sexual assault victims. Drawing upon the 2010 American Psychological Association Ethics Code, specific ethical concerns including respect for persons, competence, confidentiality and privacy, and beneficence and nonmaleficence are discussed. Recommendations for researchers studying sexual assault in college students are provided.     

Sexual Preference,Gender, and Blame Attributions in Adolescent Sexual Assault

ABSTRACT

The study investigated the impact of victim sexual orientation, perpetrator gender, and participant gender on judgements toward a 15-year-old male victim of a depicted sexual assault. One hundred and eight-eight participants (97 male, 91 female) read a hypothetical scenario depicting the sexual assault of a 15-year-old male victim where the victim's sexual orientation and the perpetrator's gender were varied between subjects. Participants then completed a questionnaire assessing their attributions toward both the victim and the perpetrator. Results revealed that male participants blamed the victim more than female participants when the victim was both gay and attacked by a male perpetrator. All participants, regardless of gender, made more positive judgements toward the female as opposed to male perpetrator. Results are discussed in relation to gender role stereotypes and homophobia.     

Primary Care Treatment Integrating Motivation and Exposure for PTSD Symptoms and Hazardous Alcohol Use: A Case Series

Symptoms of posttraumatic stress disorder (PTSD) and hazardous alcohol use are highly comorbid. Research on integrated interventions to address PTSD symptoms and hazardous alcohol use concurrently has demonstrated efficacy, yet integrated treatments are underutilized. Both patient (e.g., stigma, scheduling/logistics) and clinician (e.g., concern about symptom exacerbation and/or treatment dropout) barriers may impede utilization of integrated interventions among those with comorbid PTSD symptoms and hazardous alcohol use. Primary care behavioral health models (PCBH), in which embedded behavioral health providers deliver treatment to individuals with mild or moderate behavioral health symptoms in primary care, may help address treatment barriers by offering accessible behavioral health interventions in a destigmatizing setting. This paper presents two case examples from a randomized controlled trial testing the efficacy of an integrated intervention for PTSD symptoms and hazardous alcohol use developed for and delivered in primary care. Outcome data and session-by-session content for two participants are included, along with discussion of barriers encountered during the course of treatment. Clinician-suggested strategies for navigating barriers to facilitate utilization of integrated interventions for PTSD symptoms and hazardous alcohol use are also discussed.     

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.     

Dialectical Behavior Therapy With Prolonged Exposure for Adolescents: Rationale and Review of the Research

Among adolescents, interpersonal trauma has been associated with severe post-traumatic stress disorder (PTSD) and impairments across multiple domains of functioning (e.g., Derosa, Amaya-Jackson & Layne, 2013; Ford, Courtois, Steele, van der Hart, & Nijenhuis, 2005; van der Kolk, 2005). Such difficulties can include high-risk behaviors such as active suicidality (Middlebrooks & Audage, 2008) and nonsuicidal self-injurious behavior (NSSI; Hu, Taylor, Li, & Glauert, 2017). While there have been many advances in the treatment of trauma, treatment dropout for adolescents seeking trauma-informed treatment is predicted by diagnostic comorbidity and complexity (Sprang et al., 2013), as well as the number of traumatic events endorsed (Wamser-Nanney & Steinzor, 2016). Many traumatized adolescents with high-risk behaviors are referred to Dialectical Behavior Therapy (DBT-A). However, DBT-A does not yet include a specific, evidence-based protocol for treating PTSD, without which treatment gains may not be sustained for traumatized adolescents (Harned, Korslund, & Linehan, 2014). While Prolonged Exposure (PE) is indicated as the gold-standard treatment for PTSD and has proven effective for adolescents (PE-A; Foa, McLean, Capaldi, & Rosenfield, 2013), it has not yet been validated with adolescents who are actively suicidal. However, PE has successfully been integrated within DBT for adults with co-occurring Borderline Personality Disorder and PTSD (e.g., DBT-PE; Harned et al., 2014). Based upon this model, the current paper proposes the integration of DBT-A and PE-A to treat adolescents with interpersonal trauma who also present with high-risk behaviors. The paper discusses anticipated complications related to adapting this model for adolescents and provides direction for future research.     

Use of Internet Resources to Support Prolonged Exposure for Combat-Related PTSD

In vivo exposure as part of Prolonged Exposure (PE) requires the patient and therapist to generate a list of cues that are reminiscent of the trauma and generative of distress. In contrast to civilian trauma, it can be more challenging to build a robust in vivo hierarchy for a combat-related index trauma. Internet resources such as databases that list casualties from different wars, memorial pages of those who died in theater, and lists of unit association memberships and reunions are useful sources for in vivo hierarchies. These materials can provide opportunities for exposure to additional cues reminiscent of the traumatic event, provide information about the traumatic event that the veteran had been unable to recall, and create opportunities for veterans to reestablish relationships with veteran peers. Case illustrations are provided and reasons for caution are discussed.     

See the Triumph Healing Arts Workshops for Survivors of Intimate Partner Violence and Sexual Assault

Existing research demonstrates the potential value of arts-based interventions for survivors of abuse and other forms of trauma. The See the Triumph Healing Arts Workshops were designed to provide survivors of intimate partner violence and sexual assault with an opportunity to express themselves and connect with others through arts-based interventions. When appropriate, using the art developed through the workshops to create an art exhibit can be useful for raising awareness and giving voice to survivors in the local community. The preliminary results of the pilot evaluation suggest that the workshops were well-received and allowed participants to experience emotional expression, connection with others, and greater self-awareness.     

Working Through the Trauma of Sexual Assault in an Undergraduate Class

Processing the trauma of sexual assault is a complicated and often prolonged process that may occur both within and outside a formal psychotherapeutic context. The second author describes an undergraduate class that explores various aspects of sexual assault, followed by a paper written by a female student in which she describes how the class impacted her intellectual understanding of and emotional reactions to her own sexual victimization as a high school student. Finally, the authors discuss the concept of “working through” as it applies to recovery from sexual assault, and they propose that a didactic course experience, even if not designed as a therapeutic enterprise, may nonetheless serve such a function.