Implementation of Cognitive Therapy for PTSD in routine clinical care: Effectiveness and moderators of outcome in a consecutive sample

Abstract

ObjectiveTrauma-focused psychological treatments are recommended as first-line treatments for Posttraumatic Stress Disorder (PTSD), but clinicians may be concerned that the good outcomes observed in randomized controlled trials (RCTs) may not generalize to the wide range of traumas and presentations seen in clinical practice. This study investigated whether Cognitive Therapy for PTSD (CT-PTSD) can be effectively implemented into a UK National Health Service Outpatient Clinic serving a defined ethnically mixed urban catchment area.MethodA consecutive sample of 330 patients with PTSD (age 17–83) following a wide range of traumas were treated by 34 therapists, who received training and supervision in CT-PTSD. Pre and post treatment data (PTSD symptoms, anxiety, depression) were collected for all patients, including dropouts. Hierarchical linear modeling investigated candidate moderators of outcome and therapist effects.ResultsCT-PTSD was well tolerated and led to very large improvement in PTSD symptoms, depression and anxiety. The majority of patients showed reliable improvement/clinically significant change: intent-to-treat: 78.8%/57.3%; completer: 84.5%/65.1%. Dropouts and unreliable attenders had worse outcome. Statistically reliable symptom exacerbation with treatment was observed in only 1.2% of patients. Treatment gains were maintained during follow-up (M = 280 days, n = 220). Few of the selection criteria used in some RCTs, demographic, diagnostic and trauma characteristics moderated treatment outcome, and only social problems and needing treatment for multiple traumas showed unique moderation effects. There were no random effects of therapist on symptom improvement, but therapists who were inexperienced in CT-PTSD had more dropouts than those with greater experience.ConclusionsThe results support the effectiveness of CT-PTSD and suggest that trauma-focused cognitive behavior therapy can be successfully implemented in routine clinical services treating patients with a wide range of traumas.

Reliability of Therapist Effects in Practice-Based Psychotherapy Research: A Guide for the Planning of Future Studies

“…Interestingly, this range is comparable with the existing literature, where some studies have reported TEs near zero (e.g. Ehlers et al, 2013;Elkin et al, 2006;Owen, Tao, & Rodolfa, 2010) while other studies have reported TEs of 10% or higher (e.g. Boswell, Castonguay, & Wassermann, 2010).…”

Intensive prolonged exposure therapy for chronic PTSD patients following multiple trauma and multiple treatment attempts

“…Although replication is needed, our finding does suggest that a lack of habituation to anxiety during the early stage of iPE treatment can be used to detect those patients that are unlikely to benefit from exposure-based treatment. Also, patients living alone were more likely to belong to the Partial-responders cluster than to the Non-responders cluster, which result is in contrast to previous findings (Ehlers et al, 2013; Tarrier et al, 2000; van Minnen et al, 2002). However, it is possible that in our highly affected PTSD population, the presence of a partner helps maintain PTSD-related avoidance behaviour.…”

“…In standard weekly TFT programmes, patients characteristics are not found to be stable predictors of treatment outcome (Ehlers et al, 2013; Ehring et al, 2014; Powers et al, 2010; van Minnen, Arntz, & Keijsers, 2002; van Minnen, Harned, Zoellner, & Mills, 2012) and findings concerning (early) treatment process variables, such as fear habituation, are inconsistent (Bluett, Zoellner, & Feeny, 2014; Sripada & Rauch, 2015; van Minnen & Hagenaars, 2002). This variability might be explained by the fact that in most studies prediction analyses of associations were performed in entire and thus heterogeneous samples.…”

Returning to the scene of the trauma in PTSD treatment – why, how and when?

“…Within the Ehlers group's efficacy and effectiveness studies, in a typical 12 session CT-PTSD intervention, the site visit would be around session 9 (Ehlers et al 2003(Ehlers et al , 2005(Ehlers et al , 2013(Ehlers et al , 2014. As visiting the site can provoke a strong emotional response, many therapists will first work on other therapy tasks, such as reliving the memory in imagination, before visiting the site.…”

“…This article aims to promote the use of site visits in TF-CBT by providing a clear theoretical rationale for the technique (based predominantly around Ehlers & Clark, 2000;Ehlers et al 2003Ehlers et al , 2005Ehlers et al , 2013Ehlers et al , 2014, and presenting the available evidence regarding their use. A practical framework, with illustrative case examples, is also included, to guide therapists in how to plan and implement an effective site visit.…”