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Wigard I, Meyerbröker K, Ehring T, Topper M, Arntz A, Emmelkamp P. Skills training followed by either EMDR or narrative therapy for posttraumatic stress disorder in adult survivors of childhood abuse: a randomized controlled trial. Eur J Psychotraumatol 2024; 15:2332104. [PMID: 38629403 PMCID: PMC11025408 DOI: 10.1080/20008066.2024.2332104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 03/06/2024] [Indexed: 04/19/2024] Open
Abstract
Background: Individuals suffering from PTSD following childhood abuse represent a large subgroup of patients attending mental health services. The aim of phase-based treatment is to tailor treatment to the specific needs to childhood abuse survivors with PTSD with a Skills Training in Affective and Interpersonal Regulation (STAIR) phase, in which emotion dysregulation and interpersonal problems are targeted, and a trauma-focused phase.Objective: The purpose of this study was to compare STAIR + Eye Movement Desensitization and Reprocessing (EMDR) vs. STAIR + Narrative Therapy (NT) as treatments for PTSD following childhood-onset trauma in a routine clinical setting.Method: Sixty-eight adults were randomly assigned to STAIR/EMDR (8 STAIR-sessions followed by 12 EMDR-sessions) or STAIR/NT (8 STAIR-sessions followed by 12 NT-sessions). Assessments took place at pre-treatment, after each treatment phase and at 3 and 12 months post-intervention follow-up. Primary outcomes were interviewer-rated and self-reported symptom levels of PTSD. Secondary outcomes included symptom levels of depression and disturbances in emotion regulation and interpersonal skills.Results: Multilevel analyses in the intent-to-treat sample indicated that patients in both treatments improved substantially on PTSD symptom severity (CAPS: d = 0.81 to 1.29; PDS: d = 1.68 to 2.15), as well as on symptom levels of depression, anxiety, emotion regulation, dissociation and interpersonal skills. Effects increased or were maintained until 12-month follow-up. At mid-treatment, after STAIR, patients in both treatments improved moderately on PTSD symptom severity (PDS: d = 1.68 to 2.15), as well as on symptom levels of depression (BDI: d = .32 to .31). Symptoms of anxiety, emotion dysregulation, interpersonal problems and dissociation were not decreased after STAIR. There were no significant differences between the two conditions on any outcome.Conclusion: PTSD in adult survivors of childhood interpersonal trauma can effectively be treated by phase-based interventions using either EMDR or NT in the trauma-processing phase.Trial registration: ClinicalTrials.gov identifier: NCT01443182..
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Affiliation(s)
- I. Wigard
- Parnassiagroep, Amsterdam, the Netherlands
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, the Netherlands
| | - K. Meyerbröker
- Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands
- Altrecht Academic Anxiety Centre, Utrecht, the Netherlands
| | - T. Ehring
- Department of Psychology, LMU Munich, Munich, Germany
| | - M. Topper
- GGZ-Noord-Holland-Noord, Alkmaar, the Netherlands
| | - A. Arntz
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, the Netherlands
| | - P. Emmelkamp
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, the Netherlands
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Kim JS, Prins A, Hirschhorn EW, Legrand AC, Macia KS, Yam SS, Cloitre M. Preliminary Investigation Into the Effectiveness of Group webSTAIR for Trauma-exposed Veterans in Primary Care. Mil Med 2024:usae052. [PMID: 38442368 DOI: 10.1093/milmed/usae052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/19/2023] [Accepted: 02/07/2024] [Indexed: 03/07/2024] Open
Abstract
INTRODUCTION A substantial number of trauma-exposed veterans seen in primary care report significant symptoms of PTSD and depression. While primary care mental health integration (PCMHI) providers have been successful in delivering brief mental health treatments in primary care, few studies have evaluated interventions that combine mobile health resources with PCMHI groups. This pilot study assessed the potential benefits of webSTAIR, a 10-module transdiagnostic treatment for trauma-exposed individuals, supported by 5 biweekly group sessions delivered via telehealth. The transdiagnostic and mobile health nature of the treatment, as well as the therapist and peer support provided through group sessions, may offer an innovative approach to increasing access to patient-centered and trauma-informed treatment in primary care settings. MATERIALS AND METHODS Thirty-nine male and female veterans with trauma-related symptoms (i.e., PTSD and/or depression) participated in group webSTAIR. Mixed effects analyses were conducted to assess changes in PTSD and depression at pre-, mid-, and post-treatment. Baseline symptom severity was assessed as a predictor of module completion and group attendance. The project was part of a VHA quality improvement project, and IRB approval was waived by the affiliated university. RESULTS Analyses revealed significant pre-to-post improvement in both PTSD and depression outcomes with a large effect size for PTSD (Hedges' gav = 0.88) and medium to large for depression (Hedges' gav = 0.73). Of participants who completed the baseline assessment, 90% began webSTAIR; of those, 71% completed the program. Baseline symptoms of PTSD and depression did not predict group attendance or module completion. CONCLUSIONS Good outcomes and a satisfactory retention rate suggest that group webSTAIR may provide easily accessible, high-quality, and effective treatment for patients presenting with trauma-related problems without increasing therapist or system burdens. The results suggest the value of conducting a randomized controlled trial to test the effectiveness of group webSTAIR relative to PCMHI usual care or other evidence-based, disorder-specific (e.g., PTSD) treatments for trauma-exposed individuals in PCMHI.
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Affiliation(s)
- Jamie S Kim
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA
| | - Annabel Prins
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA
- American Lake Division, VA Puget Sound Health Care System, 9600 Veterans Drive Southwest, Tacoma, WA 98493-0003, USA 900-329-8387
| | - Elizabeth W Hirschhorn
- American Lake Division, VA Puget Sound Health Care System, 9600 Veterans Drive Southwest, Tacoma, WA 98493-0003, USA 900-329-8387
| | - Alison C Legrand
- American Lake Division, VA Puget Sound Health Care System, 9600 Veterans Drive Southwest, Tacoma, WA 98493-0003, USA 900-329-8387
| | - Kathryn S Macia
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA
| | - Sherry S Yam
- General Mental Health, VA Northern California Health Care System, 150 Muir Road, Martinez, CA 94553-4668, USA
| | - Marylene Cloitre
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA
- Department of Psychiatry and Behavioral Health Sciences, Stanford University, 401 Quarry Road, Stanford, CA 94305-5717, USA
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Sele P, Hoffart A, Cloitre M, Hembree E, Øktedalen T. Comparing phase-based treatment, prolonged exposure, and skills-training for Complex Posttraumatic Stress Disorder: A randomized controlled trial. J Anxiety Disord 2023; 100:102786. [PMID: 37871452 DOI: 10.1016/j.janxdis.2023.102786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 09/19/2023] [Accepted: 10/06/2023] [Indexed: 10/25/2023]
Abstract
OBJECTIVE This study examines treatment effects in STAIR Narrative Therapy (SNT), a phase-based treatment where Skills Training in Affective and Interpersonal Regulation (STAIR) precedes Narrative Therapy (NT), compared to Prolonged Exposure (PE) and to STAIR. METHOD Ninety-two adult patients diagnosed with DSM-5 PTSD and ICD-11 CPTSD following childhood abuse were randomly assigned to enhanced versions of SNT (12 group STAIR sessions + 8 individual NT sessions), PE (8-16 individual sessions), or STAIR (12 group STAIR sessions) provided in residential care. Outcome was assessed by mixed models. RESULTS PE produced greater improvements in DSM-5 PTSD symptoms compared to SNT from pre-treatment to post-treatment, but not compared to STAIR. Reductions in ICD-11 CPTSD symptoms were not significantly different among conditions. From pre-treatment to 1 year follow-up, PE produced greater PTSD symptom improvements than SNT and STAIR, and PE and STAIR produced greater CPTSD symptom improvements than SNT. CONCLUSIONS The predicted stronger effect of SNT compared to PE and STAIR on DSM-5 PTSD and ICD-11 CPTSD symptoms was not supported by the findings. The benefits of immediate trauma-focused treatments (TFT) as compared to phase-based treatments, and the potential non-inferiority of skills-training as compared to TFT in CPTSD needs to be further investigated.
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Affiliation(s)
- Peter Sele
- Research Institute, Modum Bad Psychiatric Hospital, Vikersund N-3370, Norway; Department of Psychology, University of Oslo, Norway.
| | - Asle Hoffart
- Research Institute, Modum Bad Psychiatric Hospital, Vikersund N-3370, Norway; Department of Psychology, University of Oslo, Norway
| | - Marylène Cloitre
- National Center for PTSD, Division of Dissemination and Training, VA Palo Alto Health Care System, CA 94025, USA; Department of Psychiatry and Behavioral Sciences, Standford University, Stanford, CA 94305, USA
| | - Elizabeth Hembree
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Tuva Øktedalen
- Research Institute, Modum Bad Psychiatric Hospital, Vikersund N-3370, Norway
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Godfrey LB, Cloitre M, Elwy AR, Fortuna LR, Fuchs C, Valentine SE. Study protocol for a hybrid 1 effectiveness-implementation trial of Brief Skills Training in Affective and Interpersonal Regulation (Brief STAIR) and web-administered STAIR (webSTAIR) for posttraumatic stress disorder in integrated primary care. Contemp Clin Trials 2023; 131:107241. [PMID: 37244367 PMCID: PMC10527289 DOI: 10.1016/j.cct.2023.107241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/06/2023] [Accepted: 05/22/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) disproportionally affects low-income, racial and ethnic minoritized communities, where prevalence is high, yet access to evidence-based treatments (EBTs) is low. As such, there is a need to identify effective, feasible, and scalable interventions for PTSD. Stepped care approaches that include brief, low-intensity treatments are one approach to improving access yet have not been developed for adults with PTSD. Our study aims to test the effectiveness of a step one PTSD treatment in primary care while gathering information on implementation to maximize sustainability in the setting. METHODS This study will be conducted in integrated primary care in the largest safety net hospital in New England using a hybrid type 1 effectiveness-implementation design. Eligible trial participants are adult primary care patients who meet full or subthreshold criteria for PTSD. Interventions include Brief clinician-administered Skills Training in Affective and Interpersonal Regulation (Brief STAIR) versus web-administered STAIR (webSTAIR) during a 15-week active treatment period. Participants complete assessments at baseline (pre-treatment), 15 weeks (post-treatment), and 9 months (follow-up) post-randomization. We will assess feasibility and acceptability post-trial using surveys and interviews with patients, study therapists, and other key informants, and will assess the preliminary effectiveness of interventions in terms of PTSD symptom change and functioning. CONCLUSION This study will provide evidence for the feasibility, acceptability, and preliminary effectiveness of brief, low-intensity interventions in safety net integrated primary care, with the aim of including these interventions in a future stepped care approach to PTSD treatment. CLINICAL TRIAL NUMBER NCT04937504.
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Affiliation(s)
- Laura B Godfrey
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA
| | - Marylène Cloitre
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA; National Center for PTSD, Dissemination and Training Division at VA Palo Alto Health Care, Palo Alto, CA, USA
| | - A Rani Elwy
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA; Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Lisa R Fortuna
- Department of Psychiatry and Behavioral Sciences at University of California, San Francisco, San Francisco, CA, USA
| | - Cara Fuchs
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA; Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Sarah E Valentine
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA; Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
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Willis N, Dowling C, O'Reilly G. Stabilisation and Phase-Orientated Psychological Treatment for Posttraumatic Stress Disorder – A Systematic Review and Meta-Analysis. EUROPEAN JOURNAL OF TRAUMA & DISSOCIATION 2022. [DOI: 10.1016/j.ejtd.2022.100311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Schleyer W, Zona K, Quigley D, Spottswood M. Group therapy in primary care settings for the treatment of posttraumatic stress disorder: A systematic literature review. Gen Hosp Psychiatry 2022; 77:1-10. [PMID: 35390567 DOI: 10.1016/j.genhosppsych.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE This systematic review aims to summarize existing literature on group therapy for the treatment of post-traumatic stress disorder (PTSD) in primary care. METHOD A PRISMA systematic literature review was performed through February 26, 2022 identifying existing studies of group trauma therapy in primary care. Articles were included if they discussed group trauma therapy for primary care patients. Bias was assessed based on sample sizes and presence of control groups. Results are presented as a weighted average of the engagement rate and a qualitative description of overlapping study traits. RESULTS Four studies of group PTSD treatment within primary care were identified with 70 total patients completing group treatment. The weighted treatment engagement rate was 65%. Each utilized distinct group trauma treatment models and reported significant patient improvements in PTSD symptoms on standardized trauma symptom scales. DISCUSSION Group trauma therapy models are available and can be disseminated within primary care settings. Limitations include both the small number of studies and participants. CONCLUSION There have been few studies of group therapy for PTSD in primary care, but these could represent a promising and scalable approach to meet the high need for trauma treatment. Further research is needed regarding implementation feasibility and impact.
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Affiliation(s)
- William Schleyer
- Cambridge Health Alliance/Harvard Medical School, Department of Psychiatry, 1493 Cambridge Street, Cambridge, MA 02139, USA
| | - Kate Zona
- Cambridge Health Alliance/Harvard Medical School, Department of Psychiatry, 1493 Cambridge Street, Cambridge, MA 02139, USA
| | - Dan Quigley
- Smith College School for Social Work Lilly Hall, 23 West St, Northampton, MA 01063, United States of America
| | - Margaret Spottswood
- Community Health Centers of Burlington, 617 Riverside Ave., Burlington, VT 05401, United States of America; University of Vermont, Department of Psychiatry, 1 South Prospect Street, Burlington, VT 05401, United States of America.
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Cloitre M, Hyland P, Prins A, Shevlin M. The international trauma questionnaire (ITQ) measures reliable and clinically significant treatment-related change in PTSD and complex PTSD. Eur J Psychotraumatol 2021; 12:1930961. [PMID: 34211640 PMCID: PMC8221157 DOI: 10.1080/20008198.2021.1930961] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The International Trauma Questionnaire (ITQ) is a validated measure that assesses ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD). An important task is to determine whether the ITQ is an appropriate evaluative measure for clinical trials. Objective: To assess the psychometric properties of the ITQ in the context of treatment and determine if the ITQ measures reliable and clinically significant change over the course of a psychosocial intervention. Method: Analyses were based on data from an online skills training programme delivered to 254 U.S. Veterans. Reliability and validity of the ITQ scores were assessed at baseline. Changes in symptom scores and probable diagnostic rates were compared at pre-, mid- and post-treatment. A reliable change index (RCI) score was computed to classify participants as improved, unchanged, or worsened. The PCL-5 was used as a comparison measure. Results: Baseline concurrent and factorial validity was similar to previous studies. Internal consistency at each assessment was excellent and comparable to the PCL-5. Decline in symptoms from pre-to-post-treatment was significant for PTSD and CPTSD symptom profiles. Rate of probable disorder (PTSD or CPTSD) declined significantly from pre-treatment to post-treatment. Pre-to-post treatment declines exceeded the critical RCI values for the ITQ. Clinically significant changes were observed where most participants improved, some stayed the same, and few worsened. The performance of the ITQ was consistent with the PCL-5 regarding sensitivity to change. Conclusion: This study provides the first demonstration that the ITQ measures reliable and clinically significant treatment-related change of ICD-11 PTSD and CPTSD symptoms.
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Affiliation(s)
- Marylène Cloitre
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Palo Alto, CA, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Philip Hyland
- Department of Psychology, National University of Ireland Maynooth, Kildare, Ireland.,Trinity Centre for Global Health, University of Dublin, Trinity College, Dublin, Ireland
| | - Annabel Prins
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Palo Alto, CA, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Mark Shevlin
- School of Psychology Derry, Ulster University, Coleraine, Northern Ireland
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Macia KS, Blonigen DM, Shaffer PM, Cloitre M, Smelson DA. Trauma-related differences in socio-emotional functioning predict housing and employment outcomes in homeless veterans. Soc Sci Med 2021; 281:114096. [PMID: 34126293 DOI: 10.1016/j.socscimed.2021.114096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/29/2021] [Accepted: 05/29/2021] [Indexed: 01/10/2023]
Abstract
RATIONALE Mental health and substance use disorders are strong risk factors for homelessness. Understanding the role of transdiagnostic factors could help inform efforts to reduce homelessness among veterans with a range of disorders. Homeless veterans have high rates of trauma exposure, which can result in the depletion of social and emotional resources that may contribute to housing and employment stability. In this study, we evaluated the role of problems with emotional lability and interpersonal closeness as transdiagnostic socio-emotional factors that might interfere with efforts to achieve housing and employment stability. METHODS The sample consisted of 346 homeless veterans with co-occurring disorders that were admitted to a U.S. Department of Veterans Affairs (VA) residential treatment program between 2004 and 2009. Assessments were conducted at treatment entry (baseline) and two follow-up timepoints (6- and 12-months). Variables used in the current analyses included history of interpersonal trauma exposure, emotional lability and interpersonal closeness at baseline and 6-months, and homelessness and employment problems during follow-up. Data were analyzed using structural equation modeling and counterfactually-defined mediation effects. RESULTS Veterans exposed to more trauma types experienced more baseline impairment and less improvement during treatment in emotional lability and interpersonal closeness. Problems with interpersonal closeness mediated 73% of the relationship between exposure to multiple traumas and homelessness, and 32%-61% of the relationship between trauma exposure and employment problems. Emotional lability mediated 36% of the relationship between exposure to multiple traumas and employment problems. Decomposition of indirect pathways revealed that indirect effects were primarily transmitted through changes during treatment, and not baseline levels. CONCLUSION Findings support a cumulative effect of trauma on persistence of socio-emotional deficits across treatment, which increased risk of homelessness and employment problems during follow-up. Greater attention and more targeted efforts should be directed at helping trauma-exposed veterans build socio-emotional resources during treatment.
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Affiliation(s)
- Kathryn S Macia
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Menlo Park, CA, 94025, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, 94304, USA.
| | - Daniel M Blonigen
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, 94304, USA; Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, 94025, USA
| | - Paige M Shaffer
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, 01655, USA
| | - Marylène Cloitre
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Menlo Park, CA, 94025, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, 94304, USA
| | - David A Smelson
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, 01655, USA; Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, 01730, USA
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