Effectiveness of the massed delivery of unified protocol for emotional disorders within an intensive outpatient program for military service members and veterans.

Recent evidence supports the implementation of massed delivery of disorder-specific treatments in the military service member and veteran population. However, many treatment settings serve patients with a wide range of diagnoses, and often patients present with comorbid conditions. Growing evidence suggests transdiagnostic cognitive behavioral treatments are effective for a wide range of emotional disorders and may reduce barriers to access. Little is known about the feasibility and outcomes of the massed delivery of transdiagnostic treatments. The present study examined real-world outcomes of a 2-week intensive outpatient program using the Unified Protocol for emotional disorders (UP-IOP). The sample included military service members and veterans diagnosed with a range of emotional disorders, namely trauma- and stressor-related disorders, unipolar depressive disorders, and anxiety disorders. The present study examined outcomes of UP-IOP (depression, trauma-related symptom severity, and emotion dysregulation). Participants included all patients who sought UP-IOP in its first 15 months of operation (N = 117). A diagnosis of posttraumatic stress disorder (PTSD) was an exclusion criterion because the site had an established PTSD-specific IOP treatment option. Findings indicate UP-IOP was feasible, had 94% patient retention, and was effective in reducing symptom severity (Cohen's d = 0.76 for depression symptom severity, Cohen's d = 0.80 for trauma-related symptom severity). There was no observed reduction in emotion dysregulation over the 2-week course of treatment. The intensive transdiagnostic approach resulted in effective symptom reduction in an accelerated timeframe while minimizing patient attrition. These findings indicate massed delivery of transdiagnostic cognitive behavioral therapy (CBT) treatments should continue to be explored, especially for this population. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Consultation competencies in prolonged exposure therapy for posttraumatic stress disorder.

INTRODUCTION: The Emory University Prolonged Exposure (PE) Consultant Training Program seeks to develop a national network of competent PE consultants. Comprehensive training in empirically supported treatment (EST), such as PE, includes a didactic training followed by a period of experiential learning through consultation during real-world clinical practice (Karlin & Cross, 2014). Expert consultants are needed to meet demand as ESTs are disseminated. METHOD: The Emory program has developed a training model to develop 18 consultation skills within five competency domains: the consultation relationship, general psychotherapy skills, PE-specific skills, trainee barriers to delivery, and implementation. RESULTS: The current article outlines these domains and discusses their theoretical background and applied value for PE consultant training, drawing on examples from the Emory program. DISCUSSION: Just as manualizing therapy has allowed for EST dissemination, the operationalizing of consultation competencies can provide a first step in disseminating evidence-based consultation practice. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Overcoming Clinician Technophobia: What We Learned from Our Mass Exposure to Telehealth During the COVID-19 Pandemic.

Mental health clinicians have migrated to telehealth during the COVID-19 pandemic and have reported their use of telehealth may be permanent. Understanding how stakeholders overcame hesitancy regarding the use of telehealth can potentially reveal how stakeholders can adopt future clinical technologies. The exposure therapy conceptual framework provides one explanation of how mental health clinicians can face their concerns about technologies that promise to improve clinical outcomes and worker well-being. We review available literature published since the start of the pandemic on the extent to which clinicians migrated to telehealth and their reactions to their transitions. In particular, we review available literature that describes negative attitudes and worries by clinicians as one of many barriers of telehealth implementation. We introduce the perspective that the necessary transition to telehealth at the start of the pandemic functioned as an exposure exercise that changed many clinicians' cognitive and emotional reactions to the use of telehealth technologies. Next, we provide guidance on how clinicians can continue taking an exposure approach to learning emerging technologies that are safe and can benefit all stakeholders. Clinicians can now reflect on how they overcame hesitancy regarding telehealth during the pandemic and identify how to build on that new learning by applying strategies used in exposure therapy. The future of clinical work will increasingly require mental health clinicians to better serve their patient populations and enhance their own well-being by overcoming technophobia, a broad term for any level of hesitancy, reluctance, skepticism, worry, anxiety, or fear of implementing technology.

Long-term effectiveness of a prolonged exposure-based intensive outpatient program for veterans with posttraumatic stress disorder.

Empirically-supported psychotherapies for posttraumatic stress disorder (PTSD) are highly effective and recommended as first-line treatments, yet dropout rates from standard outpatient therapy are high. Intensive outpatient programs (IOPs) that provide these therapies in condensed format with complementary interventions show promise, as they have demonstrated similar efficacy and higher retention rates. The current study examined initial and long-term outcomes up to 12-months following a 2-week PTSD IOP involving daily prolonged exposure therapy (PE) and adjunctive interventions for veterans and military service members. Participants (N = 376) demonstrated high retention (91%) and large effect size reductions in self-reported PTSD and depression symptoms after two weeks. Small increases in symptoms occurred after 3 months but these stabilized and large reductions compared to baseline were maintained up to 12 months. Piecewise multilevel modeling indicated that demographic variables did not predict PTSD or depression symptom trajectories. Higher PTSD and depression severity at intake predicted higher symptomatology across timepoints and larger relative gains during treatment. Greater alcohol use prior to treatment was associated with higher PTSD symptomatology but did not affect the magnitude of gains. A history of childhood sexual abuse was associated with greater reduction in depression symptoms over treatment, although this effect faded over follow-up. Together these findings underscore the long-term effectiveness of a PE-based IOP across a diverse range of veterans and service members.

Sleep disorder symptoms and massed delivery of prolonged exposure for posttraumatic stress disorder: Nodding off but not missing out.

OBJECTIVE: The impact of disrupted sleep on the effectiveness of prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD) is not well understood. Researchers have suggested that comorbid sleep disorders contribute to nonresponse by impairing therapeutic mechanisms such as emotional processing of trauma memories and extinction in cued fear conditioning. Several studies indicate daytime sleepiness, insomnia, and nightmares are correlated with PTSD symptom severity. However, a recent randomized controlled trial found that these sleep disorder symptoms did not affect PTSD symptom change over the course of massed PE (i.e., daily sessions across 2 weeks). METHOD: The current study used an ecologically valid clinical sample to examine whether daytime sleepiness, insomnia, and nightmares interfere with the slope of symptom change in massed PE. RESULTS: Results indicate that all 3 sleep disorder symptoms correlate with PTSD symptom severity on the first day of treatment but were not associated with symptom change. CONCLUSIONS: These findings are consistent with the expectation that the daily structure of massed PE may enhance treatment engagement in patients who are typically drowsy or not well-rested, thus facilitating fear extinction. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Perceived benefits and drawbacks of massed prolonged exposure: A qualitative thematic analysis of reactions from treatment completers.

OBJECTIVE: Advocates of massed prolonged exposure (PE) argue an intensive approach may address between-session distraction, avoidance, and demotivation that can result in dropout or interference with treatment engagement. Despite growing empirical support for the efficacy and effectiveness of massed PE, little evidence suggests massed PE matches patient preferences. Further, program evaluation efforts have not assessed unforeseen or underestimated benefits and drawbacks of massed PE. The current study is the first known study to assess patient reactions to massed PE. METHOD: Participants were 25 military veterans diagnosed with posttraumatic stress disorder who were accepted into a 2-week massed PE program. After the final session, participants completed a written survey using open-ended questions regarding their perceived benefits and drawbacks of massing the full PE protocol into 2 weeks. After demonstrating interrater reliability, coders used a thematic analysis approach to identify themes and subthemes in the qualitative data. RESULTS: Overall, participant reactions were much more positive (51.27%) than negative (17.77%). Participants identified benefits that are largely consistent with the justification for massed PE: (a) The structure limits distractions and avoidance, and (b) quick gains enhance motivation and engagement. With respect to drawbacks, participants identified that massed PE causes short-term discomfort and is demanding in terms of effort and time, which is also consistent with clinical theory of PE and justification for massed delivery. CONCLUSIONS: Participant reactions correspond to the rationale for massed PE; that is, participants identified that despite short-term discomfort and demands, they tend to like and benefit from the intensity of massed PE. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Creating a national network of community-based consultants in prolonged exposure for PTSD: Outcomes and lessons learned from a consultant training program.

OBJECTIVE: Dissemination of prolonged exposure (PE) for the treatment of posttraumatic stress disorder (PTSD) requires the availability of consultants who can help mental health clinicians learn to deliver the protocol faithfully and effectively. However, there is a dearth of PE consultants. We created a training program that aims to develop a national network of community-based PE consultants. The purpose of the study is to evaluate program effectiveness. METHOD: Our training program requires each consultant to provide consultation to two trainees, each of whom must treat two patients. Our team observes consultants engage with their trainees during virtual meetings and then provides feedback on each consultant's performance. Throughout the training, we collect outcome data on consultants, their trainees, and the patients of their trainees. RESULTS: We have graduated 36 consultants, representing 14 American states. The vast majority of consultants (90%) were able to meet training requirements and expectations. Additionally, the majority of the consultants' trainees (60%) demonstrated competence for independent practice as evidenced primarily by high treatment fidelity ratings across two patients. Among consultants' trainees who reached competency benchmarks, their patients had a robust decrease in PTSD symptom severity from pretreatment to posttreatment (Cohen's d = 1.69). Lastly, follow-up survey data indicated that consultants and their trainees spent more time providing PE consultation and delivering PE, respectively, after completing their training. CONCLUSIONS: Outcome data from the first six cohorts indicate feasibility and effectiveness in PE consultant training. We share lessons learned in the development, maintenance, and improvement of our consultant training program. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

An intensive outpatient program with prolonged exposure for veterans with posttraumatic stress disorder: Retention, predictors, and patterns of change.

High rates of drop-out from treatment of PTSD have challenged implementation. Care models that integrate PTSD focused psychotherapy and complementary interventions may provide benefit in retention and outcome. The first 80 veterans with chronic PTSD enrolled in a 2-week intensive outpatient program combining Prolonged Exposure (PE) and complementary interventions completed symptom and biological measures at baseline and posttreatment. We examined trajectories of symptom change, mediating and moderating effects of a range of patient characteristics. Of the 80 veterans, 77 completed (96.3%) treatment and pre- and posttreatment measures. Self-reported PTSD (p < .001), depression (p < .001) and neurological symptoms (p < .001) showed large reductions with treatment. For PTSD, 77% (n = 59) showed clinically significant reductions. Satisfaction with social function (p < .001) significantly increased. Black veterans and those with a primary military sexual trauma (MST) reported higher baseline severity than white or primary combat trauma veterans respectively but did not differ in their trajectories of treatment change. Greater cortisol response to the trauma potentiated startle paradigm at baseline predicted smaller reductions in PTSD over treatment while greater reductions in this response from baseline to post were associated with better outcomes. Intensive outpatient prolonged exposure combined with complementary interventions shows excellent retention and large, clinically significant reduction in PTSD and related symptoms in two weeks. This model of care is robust to complex presentations of patients with varying demographics and symptom presentations at baseline. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The effects of state anxiety on analogue peritraumatic encoding and event memory: introducing the stressful event segmentation paradigm.

Cognitive theories of PTSD argue that poor recall of trauma memories results from a stress-induced shift toward perceptual processing during encoding. The present study assessed the extent to which self-reported state anxiety affects event segmentation and its subsequent impact on memory performance (recall and recognition). Event segmentation is the cognitive process of condensing continuous streams of spatiotemporal information into discrete elements. In this study, undergraduates without PTSD used a computer programme to segment a stressful film and a non-stressful film and then they completed memory tasks for each film. For the stressful film, low memory performance was associated with high segmentation performance. A meditational analysis revealed high segmentation performance mediated a negative relationship between state anxiety and memory performance. Additionally, ad-hoc analyses suggest perceptual processing primarily drives segmentation of the stressful film and conceptual processing primarily drives segmentation of the non-stressful film.

Effectiveness of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders Among Veterans With Posttraumatic Stress Disorder: A Pilot Study.

Effective treatment options are needed for veterans who do not participate in trauma-focused psychotherapy. Research has yet to examine the effectiveness of transdiagnostic psychotherapy in veterans with posttraumatic stress disorder (PTSD) and co-occurring psychological disorders. This pilot study examined the effectiveness of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) delivered in a 16-week group format. We examined treatment outcomes in male and female veterans ( n = 52) in an outpatient specialty PTSD clinic at a large Veterans Affairs (VA) medical center. We hypothesized significant decreases in emotion regulation difficulty (Difficulties in Emotion Regulation Scale), PTSD symptom severity (PTSD Checklist for DSM-5), and depressive symptom severity (Patient Health Questionnaire-9). In addition, we hypothesized that reductions in emotion regulation difficulty across treatment would negatively predict PTSD and depressive symptoms at posttreatment. PTSD symptoms, depressive symptoms, and emotion regulation difficulty all evidenced significant improvements at the end of treatment relative to baseline ( ps < .001). In addition, reductions in emotion regulation across treatment were associated with lower PTSD and depressive symptoms at posttreatment ( ps < .001). This pilot study provides preliminary evidence supporting use of UP among veterans with PTSD and co-occurring disorders. Well-designed clinical trials evaluating efficacy of UP among veterans are needed.

Integrative Therapy Approaches for Posttraumatic Stress Disorder: A Special Focus on Treating Veterans.

Over the past decade, the use of integrative health modalities, such as mind-body interventions, art therapy, nutrition, and exercise, to treat stress-related mental health conditions, including posttraumatic stress disorder (PTSD), in military and veteran populations has been increasing. The use of integrative therapies for PTSD provides options for veterans who are not interested in traditional modalities, have limited access to traditional treatments, or are seeking a more comprehensive approach to managing their PTSD or subthreshold symptoms. These therapies show promise for improving overall well-being and comorbid conditions with PTSD, such as pain or migraines, but yield mixed data for PTSD symptoms. The aim of this article is to review the evidence for the most promising integrative health modalities for treating PTSD, with a special focus on the treatment of veterans, as well as to offer recommendations and suggestions for clinicians.

Registered Replication Report: Hart & Albarracín (2011).

Language can be viewed as a complex set of cues that shape people's mental representations of situations. For example, people think of behavior described using imperfective aspect (i.e., what a person was doing) as a dynamic, unfolding sequence of actions, whereas the same behavior described using perfective aspect (i.e., what a person did) is perceived as a completed whole. A recent study found that aspect can also influence how we think about a person's intentions (Hart & Albarracín, 2011). Participants judged actions described in imperfective as being more intentional (d between 0.67 and 0.77) and they imagined these actions in more detail (d = 0.73). The fact that this finding has implications for legal decision making, coupled with the absence of other direct replication attempts, motivated this registered replication report (RRR). Multiple laboratories carried out 12 direct replication studies, including one MTurk study. A meta-analysis of these studies provides a precise estimate of the size of this effect free from publication bias. This RRR did not find that grammatical aspect affects intentionality (d between 0 and -0.24) or imagery (d = -0.08). We discuss possible explanations for the discrepancy between these results and those of the original study.

A Qualitative Examination of Situational Risk Recognition Among Female Victims of Physical Intimate Partner Violence.

Little is known about intimate partner violence (IPV) victims' situational risk recognition, defined as the ability to identify situational factors that signal imminent risk of victimization. Using semi-structured interviews, qualitative data were collected from a community sample of 31 female victims of IPV episodes involving substance use. Thirteen themes were identified, the most prevalent being related to the partner's verbal behavior, tone of voice, motor behavior, alcohol or drug use, and facial expression. Participants reporting at least some anticipation of physical aggression (61.3% of the sample) tended to identify multiple factors (M = 3.47), suggesting numerous situational features often contribute to situational risk recognition.

Understanding How Grammatical Aspect Influences Legal Judgment.

Recent evidence suggests that grammatical aspect can bias how individuals perceive criminal intentionality during discourse comprehension. Given that criminal intentionality is a common criterion for legal definitions (e.g., first-degree murder), the present study explored whether grammatical aspect may also impact legal judgments. In a series of four experiments participants were provided with a legal definition and a description of a crime in which the grammatical aspect of provocation and murder events were manipulated. Participants were asked to make a decision (first- vs. second-degree murder) and then indicate factors that impacted their decision. Findings suggest that legal judgments can be affected by grammatical aspect but the most robust effects were limited to temporal dynamics (i.e., imperfective aspect results in more murder actions than perfective aspect), which may in turn influence other representational systems (i.e., number of murder actions positively predicts perceived intentionality). In addition, findings demonstrate that the influence of grammatical aspect on situation model construction and evaluation is dependent upon the larger linguistic and semantic context. Together, the results suggest grammatical aspect has indirect influences on legal judgments to the extent that variability in aspect changes the features of the situation model that align with criteria for making legal judgments.