Perceived Need for a Faith-Based Trauma-Focused Treatment in a Sample of Forcibly Displaced Muslims.

Forcibly displaced Muslims, including refugees, internally displaced persons, and asylum seekers who have fled their homes to escape violence, conflict, and persecution, often have inequitable access to quality mental health services, despite substantial trauma exposure and high rates of posttraumatic stress disorder (PTSD). Understanding factors associated with domains of perceived need (i.e., community, individual, friends/family) for culturally-responsive, trauma-focused mental health interventions among forcibly displaced Muslims may provide insight into those most likely to seek psychological treatment. A sample of 108 forcibly displaced Muslims endorsed moderate to high perceived need across all three domains for a trauma healing group tailored for Muslim refugees. PTSD severity related to perceived individual need, regardless of locus of displacement. Among participants with minimal PTSD symptoms, those who were externally displaced had higher perceived community and friends or family need than those who were internally displaced. Findings highlight a need for culturally responsive, trauma-focused mental health services to facilitate access to mental health care for forcibly displaced Muslims.

Islamic trauma healing (ITH): A scalable, community-based program for trauma: Cluster randomized control trial design and method.

Background: Somalia has long been in a state of humanitarian crisis; trauma-related mental health needs are extremely high. Access to state-of-the-art mental health care is limited. Islamic Trauma Healing (ITH) is a manualized mosque-based, lay-led group intervention aimed at healing the individual and communal mental wounds of war and refugee trauma. The 6-session intervention combines Islamic principles with empirically-supported exposure and cognitive restructuring principles for posttraumatic stress disorder (PTSD). ITH reduces training time, uses a train the trainers (TTT) model, and relies on local partnerships embedded within the strong communal mosque infrastructure. Methods: We will conduct a hybrid effectiveness-implementation randomized control trial (RCT) in the Somaliland, with implementation in the cities of Hargeisa, Borama, and Burao. In this study, a lay-led, mosque-based intervention, Islamic Trauma Healing (ITH), to promote mental health and reconciliation will be examined in 200 participants, randomizing mosques to either immediate ITH or a delayed (waitlist; WL) ITH conditions. Participants will be assessed by assessors masked to condition at pre, 3 weeks, 6 weeks, and 3-month follow-up. Primary outcome will be assessor-rated posttraumatic stress symptoms (PTSD), with secondary outcomes of depression, somatic symptoms, and well-being. A TTT model will be tested, examining the implementation outcomes. Additional measures include potential mechanisms of change and cost effectiveness. Conclusion: This trial has the potential to provide effectiveness and implementation data for an empirically-based principle trauma healing program for the larger Islamic community who may not seek mental health care or does not have access to such care. Clinical trial registration number: ClinicalTrials.gov NCT05890482. World health organization trial registration data set information: See Supplemental Appendix 1.

Temporal sequencing of change in trauma-related beliefs and therapeutic alliance during prolonged exposure and sertraline for chronic PTSD.

OBJECTIVE: Changes in trauma-related beliefs and therapeutic alliance have been found to temporally precede symptom reduction; however, it is likely these processes do not act in isolation but rather in interactive ways. METHODS: The present study examined the temporal relationships between negative posttraumatic cognitions (PTCI) and therapeutic alliance (WAI) in 142 patients who were part of a randomized trial comparing prolonged exposure (PE) to sertraline for chronic PTSD. RESULTS: Using time-lagged mixed regression models, improvements in the therapeutic alliance predicted subsequent improvements in trauma-related beliefs (d = 0.59), an effect accounted for by between-patient variability (d = 0.64) compared to within-patient variability (d = .04) giving weaker support to the causal role of alliance on outcome. Belief change did not predict improvements in alliance and neither model was moderated by treatment type. CONCLUSION: Findings suggest alliance may not be an independent driver of cognition change and point to the need for additional study of the impact of patient characteristics on treatment processes.

Within-patient association between emotion regulation and outcome in prolonged exposure for posttraumatic stress disorder.

OBJECTIVE: Difficulties with emotion regulation (ER) are a risk factor for the development and maintenance of posttraumatic stress disorder (PTSD). Less is known about temporal relations between ER and PTSD symptom change during treatment, including whether ER may represent a more potent change ingredient for some patients relative to others. This study examined the association between within-patient changes in ER and next-session PTSD symptom change and whether this association was more pronounced for patients with poorer baseline ER, more severe depression, or higher borderline personality disorder symptoms. METHOD: Data derived from a randomized controlled trial (NCT01600456) in which 149 adults with PTSD received up to 10 sessions of prolonged exposure (PE) or PE + sertraline. Patients rated difficulties with ER and PTSD symptoms repeatedly during treatment. Moderators were assessed at baseline. RESULTS: Cross-lagged, dynamic structural equation models revealed that ER improvements were associated with next-session reductions in PTSD (standardized effect = 0.13). PTSD symptom reduction was also associated with next-session ER improvement (standardized effect = 0.34). Moderator analyses revealed that the within-person ER-PTSD symptoms association was stronger for patients with higher baseline depression (standardized effect = 0.39). CONCLUSIONS: Reductions in PTSD symptoms may facilitate ER improvements during PE and PE augmented with sertraline rather than improvements in ER producing changes in PTSD symptoms. For patients with higher severity co-occurring depression, ER may represent a more active change ingredient. PE therapists could therefore consider placing particular emphasis on improving ER capabilities when working with this subgroup of patients. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Rethinking Research on Prediction and Prevention of Psychotherapy Dropout: A Mechanism-Oriented Approach.

Dropout is a ubiquitous psychotherapy outcome in clinical practice and treatment research alike, yet it remains a poorly understood problem. Contemporary dropout research is dominated by models of prediction that lack a strong theoretical foundation, often drawing on data from clinical trials that report on dropout in an inconsistent and incomplete fashion. In this article, we assert that dropout is a critical treatment outcome that is worthy of investigation as a mechanistic process. After briefly describing the scope of the dropout problem, we discuss the many factors that limit the field's present understanding of dropout. We then articulate and illustrate a transdiagnostic conceptual framework for examining psychotherapy dropout in contemporary research, concluding with recommendations for future research. With a more comprehensive understanding of the factors affecting retention, research efforts can shift toward investigating key processes underlying treatment dropout, thus, boosting prediction and informing strategies to mitigate dropout in clinical practice.

WhatsApp supervision for a lay-led Islamic trauma-focused intervention in Somaliland: Qualitative content analysis.

Clinical supervision is critical for the uptake of psychotherapy but difficult to facilitate in countries with limited providers, resources, and internet infrastructure. Innovative supervision approaches are needed to increase access to mental health treatments in low-to-middle income countries (LMICs). This study examined the content and feasibility of remote WhatsApp text supervision conducted as part of an open clinical trial in Somaliland. Islamic Trauma Healing ITH) is a brief, group, lay-lead, trauma-focused, mosque-based intervention that has demonstrated initial efficacy in pilot studies in the United States and Somaliland. After a 2-day, in-person training, lay leaders led four groups of five to seven members focused on trauma-related psychopathology and community reconciliation. Somali lay leaders trained in ITH (n = 9) and the research team (n = 6) attended weekly WhatsApp supervision during the intervention. Content was logged and subjected to qualitative analysis by two coders. Comments related to intervention implementation indicated that lay leaders understood the treatment rationale, adhered to treatment procedures, and believed the intervention components to be helpful and culturally relevant. Themes related to engagement suggested perfect attendance across groups and high levels of participation. Lay leader psychoeducation and skill development; supervisor praise, support, and encouragement; and supervisee gratitude emerged as additional themes. Remote text supervision conducted via WhatsApp was technologically feasible and may have facilitated skill development and the effective implementation of this lay-led intervention. When tailored to the local context, remote supervision approaches hold promise for increasing access to services in LMICs with limited resources.

Rare copy number variation in posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) is a heritable (h2 = 24-71%) psychiatric illness. Copy number variation (CNV) is a form of rare genetic variation that has been implicated in the etiology of psychiatric disorders, but no large-scale investigation of CNV in PTSD has been performed. We present an association study of CNV burden and PTSD symptoms in a sample of 114,383 participants (13,036 cases and 101,347 controls) of European ancestry. CNVs were called using two calling algorithms and intersected to a consensus set. Quality control was performed to remove strong outlier samples. CNVs were examined for association with PTSD within each cohort using linear or logistic regression analysis adjusted for population structure and CNV quality metrics, then inverse variance weighted meta-analyzed across cohorts. We examined the genome-wide total span of CNVs, enrichment of CNVs within specified gene-sets, and CNVs overlapping individual genes and implicated neurodevelopmental regions. The total distance covered by deletions crossing over known neurodevelopmental CNV regions was significant (beta = 0.029, SE = 0.005, P = 6.3 × 10-8). The genome-wide neurodevelopmental CNV burden identified explains 0.034% of the variation in PTSD symptoms. The 15q11.2 BP1-BP2 microdeletion region was significantly associated with PTSD (beta = 0.0206, SE = 0.0056, P = 0.0002). No individual significant genes interrupted by CNV were identified. 22 gene pathways related to the function of the nervous system and brain were significant in pathway analysis (FDR q < 0.05), but these associations were not significant once NDD regions were removed. A larger sample size, better detection methods, and annotated resources of CNV are needed to explore this relationship further.

The effect of perceived life stress on posttraumatic stress disorder treatment outcome.

Life stress following trauma exposure is a consistent predictor of the development of posttraumatic stress disorder (PTSD). However, there is a dearth of research on the effect of life stress on PTSD treatment outcomes. The current study examined the effects of pretreatment levels of perceived life stress on treatment outcome in a sample of 200 individuals with PTSD who were randomized to receive either prolonged exposure (PE) therapy or sertraline as part of a clinical trial. Life stress over the year prior to treatment significantly interacted with treatment type to predict higher residual PTSD symptom severity, as assessed using the PTSD Symptom Scale-Interview, among participants who received sertraline but not those who received PE, ß = .24, p = .017, ∆R2 = .03. These findings were similar for self-reported depression severity, ß = .27, p = .008, ∆R2 = .04. Adherence to either PE homework or sertraline compliance did not mediate this association nor did life stress predict treatment retention for either treatment arm. Higher levels of perceived life stress may serve as a prescriptive predictor of PTSD treatment outcome, with PE remaining efficacious regardless of heightened pretreatment life stress. These findings encourage clinician confidence when providing PE to individuals with higher levels of life stress. Future researchers should examine the impact of PTSD treatment on perceived and objective measures of life stress to improve treatment for individuals who experience chronic stress.

A network approach to posttraumatic stress disorder: Comparing interview and self-report networks.

OBJECTIVE: Trauma-related fear (e.g., reexperiencing), impaired reward (e.g., anhedonia), and interpersonal (e.g., detachment) processes may be functionally intertwined, giving rise to chronic psychopathology after a trauma. Network analyses can help pinpoint symptom drivers and treatment targets, but studies examining posttraumatic stress disorder (PTSD) treatment-seeking individuals are lacking. METHOD: Treatment-seeking adults with primary PTSD (N = 350) completed interview and self-report measures of PTSD severity (PSS-I; PSS-SR). Self-report and interview-based networks were estimated and compared. RESULTS: Both networks suggested distinct but interconnected communities of reexperiencing and dysphoric symptoms (e.g., interpersonal detachment, numbing). Centrality profiles were strongly associated across networks (rs = .71), with cued reexperiencing and interpersonal detachment showing strong centrality. Self-reported symptoms were more interconnected, suggesting lower specificity. CONCLUSIONS: For those seeking treatment, interrelated fear and interpersonal processes may drive functional impairment in PTSD, and interview-based networks may help better delineate influential symptoms. Therapeutically, targeting cued reexperiencing and interpersonal detachment may facilitate broader symptom decreases. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Bridging the science-practice gap in treatment for posttraumatic stress disorder: Testing strategies to enhance beliefs toward exposure therapy.

OBJECTIVE: Exposure therapies (e.g., prolonged exposure [PE]), are first-line interventions for posttraumatic stress disorder but remain underutilized, partially due to providers' negative beliefs about these interventions. We examined two experimental strategies aimed at enhancing beliefs towards PE and subsequent utilization. METHOD: Clinicians (N = 155) were randomized to one of three conditions presenting a PE rationale: basic, empirically-based, or emotionally-based description. Participants were rerandomized to write or not write arguments for utilizing PE. Before and after PE rationales and 1-month later, participants completed questions about PE beliefs and utilization. RESULTS: Participants reported small yet durable belief change across all rationale conditions, with greatest change following the empirically-based description. Across conditions, belief change was not impacted by writing condition or associated with utilization. CONCLUSION: Addressing negative beliefs with empirical information may be a brief, cost-effective strategy to improve clinicians' beliefs toward PE. Complementary strategies that leverage belief modification to increase utilization are needed.

Examining Individual and Synergistic Contributions of PTSD and Genetics to Blood Pressure: A Trans-Ethnic Meta-Analysis.

Growing research suggests that posttraumatic stress disorder (PTSD) may be a risk factor for poor cardiovascular health, and yet our understanding of who might be at greatest risk of adverse cardiovascular outcomes after trauma is limited. In this study, we conducted the first examination of the individual and synergistic contributions of PTSD symptoms and blood pressure genetics to continuous blood pressure levels. We harnessed the power of the Psychiatric Genomics Consortium-PTSD Physical Health Working Group and investigated these associations across 11 studies of 72,224 trauma-exposed individuals of European (n = 70,870) and African (n = 1,354) ancestry. Genetic contributions to blood pressure were modeled via polygenic scores (PGS) for systolic blood pressure (SBP) and diastolic blood pressure (DBP) that were derived from a prior trans-ethnic blood pressure genome-wide association study (GWAS). Results of trans-ethnic meta-analyses revealed significant main effects of the PGS on blood pressure levels [SBP: ß = 2.83, standard error (SE) = 0.06, p < 1E-20; DBP: ß = 1.32, SE = 0.04, p < 1E-20]. Significant main effects of PTSD symptoms were also detected for SBP and DBP in trans-ethnic meta-analyses, though there was significant heterogeneity in these results. When including data from the largest contributing study - United Kingdom Biobank - PTSD symptoms were negatively associated with SBP levels (ß = -1.46, SE = 0.44, p = 9.8E-4) and positively associated with DBP levels (ß = 0.70, SE = 0.26, p = 8.1E-3). However, when excluding the United Kingdom Biobank cohort in trans-ethnic meta-analyses, there was a nominally significant positive association between PTSD symptoms and SBP levels (ß = 2.81, SE = 1.13, p = 0.01); no significant association was observed for DBP (ß = 0.43, SE = 0.78, p = 0.58). Blood pressure PGS did not significantly moderate the associations between PTSD symptoms and blood pressure levels in meta-analyses. Additional research is needed to better understand the extent to which PTSD is associated with high blood pressure and how genetic as well as contextual factors may play a role in influencing cardiovascular risk.

Reaching the Unreached: Bridging Islam and Science to Treat the Mental Wounds of War.

Radical new paradigms are needed to equip non-professionals and leverage community faith-based infrastructure to address the individual and communal wounds of war- and conflict-related trauma. Muslims in war-torn regions like Somalia experience high rates of trauma and posttraumatic stress; yet, lack of providers, potential stigma, and lack of integration with one's faith are substantial barriers to care. In this pre-post feasibility clinical trial (NCT03761732), mosque leaders implemented a brief, group- and mosque-based intervention, Islamic Trauma Healing, targeting trauma-related psychopathology and community reconciliation for trauma survivors (N = 26) in Somaliland, Somalia. Leaders were trained in a brief 2-day training, with supervision provided remotely via WhatsApp. This six-session intervention combines empirically-supported trauma-focused psychotherapy and Islamic principles, focusing on wisdom from the lives of the Prophets and turning to Allah in dua about trauma. There were large, clinically meaningful effects for PTSD (g = 1.91), depression (g = 2.00), somatic symptoms (g = 2.73), and well-being (g = 1.77). Qualitative data from group members highlighted how well the program was aligned with their Islamic faith, built community, and need to expand the program. These results highlight the feasibility of this non-expert, easily up-scalable mental health approach in war-torn Muslim regions and refugee communities. This program has the potential to provide a low-cost, self-sustaining, Islam-based intervention addressing the psychological wounds of war consistent with the IOM's call to develop novel approaches to address unmet clinical needs. ClinicalTrials.gov Identifier: NCT03761732.

Exposure Therapy Beliefs and Utilization for Treatment of PTSD: A Survey of Licensed Mental Health Providers.

Exposure-based therapies for posttraumatic stress disorder (PTSD) and anxiety disorders remain underutilized, despite their effectiveness and widescale dissemination efforts. This study surveyed a broad range of licensed providers (N = 155) to examine rates at which prolonged exposure (PE) and other interventions are used to treat PTSD and to investigate provider characteristics linked to exposure beliefs and utilization. While 92.3% of clinicians reported understanding of or training in exposure, only 55.5% of providers reported use of PE to treat PTSD. Clinicians with current cognitive behavioral therapy (CBT) orientation, CBT training orientation, a doctoral degree, and training in PE endorsed greater likelihood of exposure utilization for PTSD (ps < .001, ds = 0.82-1.98) and less negative beliefs about exposure (ps < .01, ds = 0.55-2.00). Exposure beliefs also differed based on healthcare setting (p < .001). Among providers trained in exposure (n = 106), master's degree and non-CBT current theoretical orientation were associated with high utilization yet also negative beliefs. Results suggest exposure training, accurate beliefs, and utilization still lag among some groups of providers. Additionally, negative beliefs and misunderstanding of the exposure rationale may persist even among providers who are trained and report high utilization.

Latent Profiles of Comorbid Depression as Predictors of PTSD Treatment Outcome.

Posttraumatic stress disorder (PTSD) frequently co-occurs with major depressive disorder, and empirically supported PTSD treatments consistently improve depression. However, both diagnoses are heterogeneous and specific patterns of symptom overlap may be related to worse treatment outcome. Two hundred individuals with chronic PTSD participated in a doubly randomized preference trial comparing prolonged exposure and sertraline. Latent Profile Analysis was used to identify classes based on PTSD and depression symptoms prior to starting treatment. A three-class model best fit the data, with a high depression and PTSD severity class (distressed), a moderate depression and low PTSD avoidance class (depressive), and a low depression and high PTSD avoidance class (avoidant). The avoidant class showed the lowest rates of major depressive disorder diagnosis and transdiagnostic vulnerabilities to depression. Patients in the distressed class experienced more robust PTSD treatment response, with no differences between prolonged exposure and sertraline. These findings highlight the role of avoidance in nondepressed PTSD presentations while also demonstrating that co-occurring depression is not contraindicated in evidence-based PTSD treatment.

Islamic Trauma Healing: Integrating Faith and Empirically Supported Principles in a Community-Based Program.

Access to adequate, much less state-of-the-art, mental health care is a global problem. Natural disasters, civil war, and terrorist conflict have forcibly displaced millions of Muslims and have resulted in a remarkable level of individual and communitywide trauma exposure. As a result, many are at risk for posttraumatic stress and other trauma-related disorders. Many religiously oriented Muslims traditionally rely on Islamic principles and teachings, as well as their community, to cope with and address trauma-related distress. Islamic Trauma Healing is a six-session, lay-led group intervention developed within a Somali Muslim community that integrates evidence-based trauma-focused cognitive-behavioral therapy principles with cultural and religious practices aimed to enhance uptake and create an easily up-scalable intervention for a wide range of trauma. In sessions, narratives of prophets who have undergone trauma (e.g., Prophet Ayyub, faith during hard times) present Islamic principles and facilitate cognitive shifts. Group members spend individual time turning to Allah in dua (i.e., informal prayer), focused on exposure to trauma memories. Program themes arc across suffering to healing to growth following trauma. This paper describes the core theoretical principles and methods in the Islamic Trauma Healing program. We also describe leader perspectives and the program's train-the-trainer model, in which lay leaders are trained to further disseminate the program and allow Islamic Trauma Healing to be owned and sustained by the Muslim community.

Transdiagnostic emotion regulation processes explain how emotion-related factors affect co-occurring PTSD and MDD in relation to trauma.

BACKGROUND: Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) co-occur at high rates and greater disorder severity. Studies examining the contributions of specific emotion regulation (ER) processes and negative affect (NA) to PTSD and MDD co-occurrence are scarce. This study investigated a transdiagnostic understanding of the nature of PTSD and MDD co-occurrence by examining the roles of NA, ER processes, and negative mood regulation (NMR) expectancies in PTSD and MDD in relation to trauma. METHODS: Structural equation modeling was used to examine the roles of emotionality, PTSD, and MDD constructs in 200 individuals with primary PTSD. RESULTS: ER processes fully mediated the relationships between NA and PTSD (ß = .40, p < .001) and MDD (ß = .48, p < .001), and NMR expectancies and PTSD (ß = -.31, p < .001) and MDD (ß = -.37, p < .001). CONCLUSIONS: NA and NMR expectancies exert their effects on PTSD and MDD almost entirely through ER processes. ER appears to be a transdiagnostic process, partly accounting for the co-occurrence between PTSD and MDD. Co-occurrence models could benefit by incorporating ER processes to inform diagnostic classification and criteria and clinical intervention improved by specifically targeting ER processes.

The Effect of Concurrent Depression on PTSD Outcomes in Trauma-Focused Psychotherapy: A Meta-Analysis of Randomized Controlled Trials.

The co-occurrence of depression with posttraumatic stress disorder (PTSD) is common and associated with greater severity and impairment than PTSD alone, but the effects on PTSD treatment outcomes are unclear. This study investigated the impact of baseline depression on PTSD symptom change and dropout in a meta-analysis of 44 randomized controlled trials (N = 4,866) of trauma-focused psychotherapies for PTSD. Analyses included 107 active (k = 71) and control (k = 36) conditions. Baseline depression was indexed within samples as (a) continuous symptom severity (e.g., Beck Depression Inventory), standardized across depression measures and (b) proportion of patients with comorbid depressive disorder diagnosis. Among active conditions reporting continuous depression scores (k = 62), greater depression severity predicted smaller PTSD treatment effect sizes (ß = -.36, p = .002), but not dropout (ß = .25, p = .18). Categorical depressive diagnosis rates (k = 29)-reported less frequently-were not associated with treatment effects or dropout in active conditions. Greater depression severity may reflect a risk factor for attenuated response in PTSD psychotherapies, potentially demanding complementary strategies within trauma-focused interventions. Variability between trials in baseline depression symptoms may suggest the need to consider this sample characteristic when comparing treatment outcomes across studies.

Differentiating "types" of treatment dropout: Nonstarters in an RCT of prolonged exposure versus sertraline.

Despite effective interventions for posttraumatic stress disorder (PTSD), many patients prematurely drop out. Differentiating "types" of dropout at various stages of treatment may improve our ability to predict and prevent attrition. Using data from a doubly randomized preference trial, this study examined patient dropout prior to treatment and compared these "nonstarters" with treatment starters and in-treatment dropouts. Patients (N = 200) with chronic PTSD were randomized to "choice" (prolonged exposure [PE] or sertraline) or "no choice" (re-randomized to PE or sertraline) and received up to 10 weeks of treatment. Overall dropout rate was 33.0% (n = 66). A substantial minority were nonstarters (n = 19; 28.8%). Relative to patients who began treatment, nonstarters reported less severe PTSD symptomatology (p = .03, d = 0.57) and were less likely to have received their preferred treatment (p < .001). These differences remained even when comparing nonstarters to patients that began treatment but eventually dropped out. Differences in beliefs (i.e., perceived credibility) toward one treatment versus the other were also linked to pretreatment dropout. Reasons underlying dropout likely differ during various treatment stages. Better understanding risk factors for types of dropout may inform strategies to boost engagement and retention, ultimately improving patient outcomes.

Imaginal exposure exacerbation revisited: Deconstructing patient characteristics associated with worse reactions to the initiation of imaginal exposure in PTSD.

OBJECTIVE: This study examines whether imaginal exposure leads to symptom exacerbation, systematically comparing individuals who received prolonged exposure (PE) to those who received pharmacotherapy. The study also examined whether common clinical features increase the likelihood of symptom exacerbation. METHOD: In 151 men and women with PTSD, we examined rates of reliable exacerbation of PTSD and depression symptoms after initiation of imaginal exposure and compared it to those receiving sertraline. We also examined relationships between exacerbation, treatment outcome, dropout, imaginal distress, and specific clinical features, including co-occurring MDD, multiple co-occurring disorders, childhood sexual abuse as target trauma, and a history of childhood physical or sexual abuse. RESULTS: Symptom exacerbation was not more common in PE compared to sertraline, not associated with higher dropout, or predictive of worse outcome. Those with co-occurring depression or multiple disorders, a target trauma of child sexual abuse, or a history of child abuse reported functionally equivalent peak distress at onset of imaginal as those without these characteristics. These factors did not lead to more exacerbation or worse adherence. CONCLUSION: Exacerbation was not specific to PE and patients with and without symptom worsening showed comparable treatment gains, suggesting symptom exacerbation may reflect a common clinical process.

Therapeutic alliance as a mediator of change: A systematic review and evaluation of research.

The alliance-outcome relationship has been consistently linked to positive treatment outcomes irrespective of psychotherapy modality. However, beyond its general links to favorable treatment outcomes, it is less clear whether the alliance is a specific mediator of change and thus a possible mechanism underlying psychotherapy response. This systematic review evaluated research examining the alliance as a potential mediator of symptom change, reviewing study characteristics of 37 relevant articles examining the alliance-outcome relationship and the extent to which these studies met recommended criteria for mechanistic research. Alliance mediated therapeutic outcomes in 70.3% of the studies. We observed significant heterogeneity across studies in terms of methodology, including timing of alliance assessment, study design, constructs used in mediation models, and analytic approaches. Building on recent methodological advancements, we propose directions for future research examining the putative mediational role of alliance, such as greater uniformity in and attention to study design and statistical methodology. This review highlights the importance of alliance in therapeutic change and discusses how adhering to requirements for process research will improve our ability to more precisely estimate how and to what extent alliance drives therapeutic change.