Predictors of treatment completion in group psychotherapy for male veterans with posttraumatic stress disorder.

Group therapy is a frequently used therapy format for posttraumatic stress disorder (PTSD). However, factors contributing to treatment completion remain understudied. The current study examined predictors of treatment completion, defined as having completed 10 out of 14 sessions within 16 weeks, in veterans with PTSD who engaged in a hybrid efficacy-effectiveness randomized controlled trial of group psychotherapy for PTSD. Veterans (N = 198) were randomly assigned to 14 sessions of either group cognitive behavioral treatment (GBCT; n = 98) or group present-centered treatment (GPCT; n = 100). Four primary domains of predictors were examined, encompassing sociodemographic factors, the severity of PTSD and comorbid conditions, modifiable predictors, and treatment condition. Multilevel binomial logistic regression models following the Fournier analysis approach were used to examine significant predictors within domains, which were then included in a final model. Overall, 70.7% of participants completed treatment (GCBT = 61.6%, GPCT = 79.8%). Participants in the GPCT condition were 2.389 times, 95% CI [1.394, 4.092], more likely to complete treatment than those in the GCBT condition. Older age, a higher income and level of educational attainment, more lifetime and current mental health diagnoses, and higher use of positive reappraisal ER skills predicted treatment completion. Higher levels of depressive symptoms, cumulative trauma burden, and use of positive refocusing ER skills predicted treatment noncompletion. These findings are discussed in the context of current clinical and research practices for examining treatment noncompletion, with attention to the inclusion of translational predictors.

Suppression and acceptance in unipolar depression: Short-term and long-term effects on emotional responding.

OBJECTIVES: Transdiagnostic treatments increasingly include emotion regulation training focused on use of emotional suppression and acceptance. Despite the frequent use of these treatments in depression, little is known about the effects of these strategies in this population. DESIGN: An experimental study. METHODS: Eighty Veterans with unipolar depression participated in a study examining effects of these strategies on emotional responding (subjective, behavioural, and physiological). Physiological measures included: heart rate (HR), respiration (Resp), skin conductance (SC), and corrugator electromyography. On Day 1, participants were randomised to one of three conditions (acceptance, suppression, or control) and underwent an autobiographical sad mood induction. On Day 2, participants underwent a similar mood induction one week later. RESULTS: The suppression group demonstrated reduced physiological reactivity (Resp and SC) on Day 1. However, the suppression group reported decreased positive affect on Day 2. CONCLUSIONS: Results support short-term effectiveness and longer term costs from suppression use among depressed individuals. Findings may inform application of transdiagnostic emotion regulation treatments and suggest suppression functions differently in depressed versus other clinical populations.

The Use of a Brief Family Intervention to Reduce Dropout Among Veterans in Individual Trauma-Focused Treatment: A Randomized Controlled Trial.

Dropout from trauma-focused treatment for posttraumatic stress disorder (PTSD) represents a daunting challenge for the field, particularly among military and veteran samples. Family involvement may help to increase the effectiveness of PTSD treatment while also improving retention. We tested a two-session brief family intervention (BFI) protocol delivered as an adjunct to individual trauma-focused treatment among a sample of 20 veteran-family member dyads (N = 40). Willingness to participate in the family-inclusive protocol was high, with over 85% of veterans and family members who were screened agreeing to take part. All enrolled veterans were beginning a course of either cognitive processing therapy (CPT) or prolonged exposure (PE), delivered in outpatient Veterans Affairs clinics. Family members were randomized to either receive or not receive the BFI from study clinicians. In the BFI condition, 20.0% of veterans dropped out of CPT/PE before the 16-week study end; the remainder were either still attending on-protocol sessions or had completed the full protocol. In the control condition, 40.0% of veterans dropped out of CPT/PE before the end of the study. Observed significant, large-magnitude decreases in PTSD symptoms over time did not differ by condition, ESsg range = -1.12 to -2.04. Accommodation did not significantly decrease over time in either condition, ESsg range = 0.18 to -0.98. The BFI represents a promising option for veterans, family members, and clinicians who are seeking a brief, feasible, narrowly focused method for incorporating families into veterans' individual trauma-focused therapy and potentially reducing the rate of dropout.

Seeking to Understand the Conditions Under Which Exposure-Based Writing Therapy for Posttraumatic Stress Disorder is an Effective Approach: A Commentary on Dawson et al. (2020).

Exposure-based writing interventions for posttraumatic stress disorder (PTSD) have shown promise when compared with waitlist conditions, placebo writing control conditions, and evidence-based, trauma-focused treatments. Recently, Dawson et al. (2020) conducted a systematic review and meta-analysis to examine existing published randomized controlled trials investigating exposure-based writing interventions. The findings were encouraging; however, the studies included in the meta-analysis had a high degree of methodological heterogeneity. Our own work examining exposure-based writing as an intervention for PTSD has demonstrated that methodological differences in the structure of exposure-based writing can have a meaningful impact on treatment outcome. Accordingly, we urge caution in interpreting the meta-analysis findings reported by Dawson and colleagues and encourage investigation into better understanding the mechanisms underlying exposure-based writing interventions to further propel this important area of work.

Development and initial testing of a brief adjunctive intervention for family members of veterans in individual PTSD treatment.

Family involvement in the treatment of posttraumatic stress disorder (PTSD) among veterans has the potential to improve treatment retention and outcomes. Current protocols that incorporate family members into treatment tend to involve at least 15 sessions, and none are designed to complement Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE), the two most widely used and heavily promoted evidence-based PTSD therapies in the Veterans Affairs (VA) healthcare system. The current paper describes the development and initial feasibility and acceptability of a Brief Family Intervention (the BFI) designed to be delivered as an adjunct to veterans' individual CPT/PE. The BFI focuses on providing psychoeducation about PTSD and treatment, building family member support for treatment, and reducing family symptom accommodation. A detailed review of the treatment structure and activities is provided, and qualitative data from four dyads (veterans and their spouses/significant others) at baseline and post-intervention are presented. Veterans and partners reported positive responses to the program and were enthusiastic about its utility. Larger randomized controlled studies will be needed to determine the protocol's efficacy and effectiveness.

Training During a Pandemic: Successes, Challenges, and Practical Guidance From a Virtual Facilitated Learning Collaborative Training Program for Written Exposure Therapy.

In response to COVID-19, continued workforce training is essential to ensure that evidence-based treatments are available on the frontline to meet communities' ongoing and emerging mental health needs. However, training during a pandemic imposes many new challenges. This paper describes a multisite training and implementation pilot program, facets of which allowed for continued training despite the onset of the COVID-19 pandemic and subsequent social distancing guidelines. This virtual facilitated learning collaborative in Written Exposure Therapy, an evidence-based treatment for posttraumatic stress disorder, included virtual workshop training, phone-based clinical consultation, implementation-focused video calls for program leadership, and program evaluation. Data are presented about program enrollees and patient impact following the onset of COVID-19-related social distancing restrictions. Challenges, successes, and practical guidance are discussed to inform the field regarding training strategies likely to be durable in an uncertain, dynamic healthcare landscape.

Long-term treatment gains of a brief exposure-based treatment for PTSD.

BACKGROUND: Written exposure therapy (WET) is a 5-session PTSD treatment that may address barriers in treatment for posttraumatic stress disorder (PTSD) given its brevity and tolerability. A recent study found outcomes for WET were non-inferior to outcomes from Cognitive Processing Therapy (CPT) through 36 weeks from first treatment session (Sloan, Marx, Lee, & Resick, 2018); the current study examined whether treatment gains were maintained through 60 weeks from first session, and also evaluated both treatments' effect on depressive symptoms. METHODS: The study enrolled 126 individuals with PTSD randomized to WET or CPT. Assessments were conducted at baseline and 6, 12, 24, 36, and 60 weeks following the first treatment session. PTSD diagnosis and symptom severity were determined via the Clinician Administered PTSD Scale for DSM-5 (CAPS-5), and depression symptoms were assessed using the Beck Depression Inventory-2. RESULTS: WET remained non-inferior to CPT through the 60 week assessment; the groups had a difference of less than 3 points in their total CAPS-5 scores, and within-condition effects on PTSD were large (WET d = 1.23; CPT d = 1.38). Both treatments significantly reduced depressive symptoms over the 60 week study, with the CPT group experiencing a more rapid decrease. The between-condition effect of treatment on depression was small (d = .19). CONCLUSIONS: WET is a treatment that is non-inferior to CPT with regard to PTSD symptoms, with treatment effects that are long-lasting. Additionally, both WET and CPT demonstrated substantial effects on depressive symptoms. WET should be considered a good option for PTSD treatment.

A longitudinal study of risk factors for suicide attempts among Operation Enduring Freedom and Operation Iraqi Freedom veterans.

BACKGROUND: Suicide rates among veterans have increased markedly since the onset of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF; LeardMann et al., 2013). Identification of factors with the greatest contribution to suicide risk among veterans is needed to inform risk assessment and to identify intervention targets. METHODS: This study examined predictors of suicide attempts among participants in the Veterans After-Discharge Longitudinal Registry; a nationwide cohort of OEF/OIF veterans enrolled in Department of Veterans Affairs (VA) services. Veterans with and without probable posttraumatic stress disorder (PTSD) were sampled at a 3:1 ratio, and male and female veterans were sampled at a 1:1 ratio. Participants (N = 1,649) were assessed at two time points, roughly 2 years apart (M = 28.74 months, SD = 8.72). RESULTS: Seventy-four participants (4.49%) attempted suicide during the follow-up period. The strongest predictors of suicide attempts among the full sample were suicidal intent, attempt history, suicide ideation, PTSD symptoms, alcohol use disorder (AUD) symptoms, and depression. Veterans with multiple risk factors were particularly vulnerable; of veterans with 0, ≥1, ≥2, ≥3, or ≥ 4 of these risk factors, 0%, 7.81%, 10.31%, 18.45%, and 20.51% made a suicide attempt, respectively. CONCLUSIONS: This prospective study identified several strong predictors of suicide attempts among OEF/OIF veterans which may be important targets for suicide prevention efforts. Further, co-occurrence of multiple risk factors was associated with markedly greater risk for suicide attempts; veterans with multiple risk factors appear to be at the highest risk among OEF/OIF veterans enrolled in VA care.

A Randomized Controlled Trial of Group Cognitive Behavioral Treatment for Veterans Diagnosed With Chronic Posttraumatic Stress Disorder.

Relative to advances in the literature that have examined individual treatment approaches for posttraumatic stress disorder (PTSD), scientific knowledge about group treatment approaches has lagged, resulting in no currently available group treatment for PTSD despite the frequency with which this format is used. Our goal was to build upon the existing literature by examining the efficacy of a group cognitive-behavioral treatment (GCBT) for PTSD relative to group present-centered treatment (GPCT). The sample consisted of 198 male veterans with PTSD who were recruited at two Department of Veteran Affairs medical centers and randomly assigned to either GCBT (n = 98) or GPCT (n = 100); both treatments were 14 sessions. Assessments occurred at baseline, midtreatment, posttreatment, and 3-, 6-, and 12-month follow-ups. Findings indicated significant reductions in PTSD severity and PTSD diagnostic status following treatment for both GCBT, d = 0.97, and GPCT, d = 0.61. In addition, we observed significant reductions for depression symptoms, anxiety symptoms, and functional impairment for both group treatments as well as a reduction in the percentage of veteran participants who met diagnostic status for co-occurring major depression disorder and generalized anxiety disorder. Notably, these treatment gains were maintained at 12-month follow-up. Contrary to expectations, there were no significant differences between treatment conditions. Veterans diagnosed with PTSD were successfully treated using a group approach. Consistent with a growing body of evidence, the findings also suggest GPCT is as equally efficacious as group trauma-focused treatment. The trial was registered at clinicaltrials.gov (NCT01544088).

Alliance across group treatment for veterans with posttraumatic stress disorder: The role of interpersonal trauma and treatment type.

OBJECTIVE: Examine initial levels and pattern of change of alliance in group treatment for posttraumatic stress disorder (PTSD) for veterans. METHOD: One hundred and seventy-eight male veterans with PTSD were recruited for this study. Participants were randomly assigned to either group cognitive behavioral therapy (GCBT) or to group present-centered therapy (GPCT). Alliance with fellow group members was assessed every other session throughout the group (total of seven assessments). Hierarchical linear modeling was used to determine whether treatment condition or index trauma type (interpersonal or non-interpersonal) impacted initial levels of alliance or change in alliance over time. RESULTS: Alliance increased significantly throughout treatment in both conditions. The presence of an interpersonal index event, compared to a non-interpersonal index event, did not significantly impact either initial levels of alliance or change in alliance over time. Participants in the GCBT condition experienced significantly greater growth in alliance over time compared to those in the GPCT condition (p > .05), but did not have significantly different initial alliance ratings. CONCLUSIONS: The components and focus of the GCBT treatment may have facilitated more rapid bonding among members. Interpersonal traumatic experience did not negatively impact group alliance.

The Association Between Peritraumatic Dissociation and PTSD Symptoms: The Mediating Role of Negative Beliefs About the Self.

Peritraumatic dissociation, a term used to describe a complex array of reactions to trauma, including depersonalization, derealization, and emotional numbness, has been associated with posttraumatic stress disorder (PTSD) symptoms across a number of studies. Cognitive theory suggests that interpretations of traumatic events and reactions underlie the persistence of PTSD. The present study examined the associations among peritraumatic dissociation, posttraumatic cognitions, and PTSD symptoms in a group of trauma-exposed adults (N = 169). Results indicated that, after accounting for overall symptom severity and current dissociative tendencies, peritraumatic dissociation was significantly predictive of negative beliefs about the self (R2 = .06, p < .001). Other categories of maladaptive posttraumatic cognitions did not show a similar relationship (R2 = .01 to .02, nonsignificant). Negative thoughts about the self partially mediated the association between peritraumatic dissociation and PTSD severity (completely standardized indirect effect = .25). These findings lend support to cognitive theories of PTSD and point to an important area for clinical intervention.

Development and Initial Psychometric Evaluation of the Semi-Structured Emotion Regulation Interview.

Emotion regulation (ER) strategy use has been identified as a transdiagnostic predictor of the development, maintenance, and recovery from several forms of psychopathology. However, the ER strategy use literature relies primarily on self-report measures that have several important limitations. This article describes the development and initial psychometric evaluation of a novel clinician-administered measure of ER strategy use, the Semi-Structured Emotion Regulation Interview (SERI; Lee, Weathers, & Sloan, 2016 ). The SERI was developed in a construct validation framework with emphasis on a multistage content validity process. The SERI assesses frequency and efficacy (i.e., proximal change in the targeted emotion) of 9 strategies in regulation of a specified emotion type and intensity (e.g., severe anxiety) during the past 30 days. Undergraduates (N = 68) completed a battery of self-report measures and a subsequent interview. Frequency and efficacy of each strategy was assessed separately with respect to regulation of moderate and severe anxiety and anger. Each of the assessed strategies demonstrated excellent discriminant validity. Associations between SERI and self-report measures of ER strategy use varied by target emotion type and intensity for some strategies, but not others. Implications and suggestions for future research are described.

Investigating the Aftermath of Terror: Fundamental Outcomes, Methodological Choices, and Future Directions.

Acts of terrorism are becoming increasingly common throughout the world. These events represent a significant public health concern given the associated health consequences. Although it is clear that terrorist attacks have mental and physical health sequelae, the exact nature and prevalence of these consequences are unclear. Epidemiological research can play an important role in better understanding the mental and physical impact of terrorist attacks. In this editorial, we highlight recent epidemiological research on these terrorism-related health outcomes. We also provide suggestions for how future studies can build on the existing literature and describe ways in which epidemiological methods can be harnessed to extend the current literature. Lastly, we offer recommendations on how to best prepare communities for the aftermath of terrorist attacks, highlighting secondary intervention and prevention strategies. Overall, multilevel strategies are needed to adequately cope with the growing rise of terrorist acts, and these strategies will have to be reassessed as the nature of terrorist attacks changes.

CRITICAL ANALYSIS OF THE CURRENT TREATMENT GUIDELINES FOR COMPLEX PTSD IN ADULTS.

According to current treatment guidelines for Complex PTSD (cPTSD), psychotherapy for adults with cPTSD should start with a "stabilization phase." This phase, focusing on teaching self-regulation strategies, was designed to ensure that an individual would be better able to tolerate trauma-focused treatment. The purpose of this paper is to critically evaluate the research underlying these treatment guidelines for cPTSD, and to specifically address the question as to whether a phase-based approach is needed. As reviewed in this paper, the research supporting the need for phase-based treatment for individuals with cPTSD is methodologically limited. Further, there is no rigorous research to support the views that: (1) a phase-based approach is necessary for positive treatment outcomes for adults with cPTSD, (2) front-line trauma-focused treatments have unacceptable risks or that adults with cPTSD do not respond to them, and (3) adults with cPTSD profit significantly more from trauma-focused treatments when preceded by a stabilization phase. The current treatment guidelines for cPTSD may therefore be too conservative, risking that patients are denied or delayed in receiving conventional evidence-based treatments from which they might profit.

Punishment Learning in U.S. Veterans With Posttraumatic Stress Disorder.

Learning processes have been implicated in the development and course of posttraumatic stress disorder (PTSD); however, little is currently known about punishment-based learning in PTSD. The current study investigated impairments in punishment-based learning in U.S. veterans. We expected that veterans with PTSD would demonstrate greater punishment-based learning compared to a non-PTSD control group. We compared a PTSD group with and without co-occurring depression (n = 27) to a control group (with and without trauma exposure) without PTSD or depression (n = 29). Participants completed a computerized probabilistic punishment-based learning task. Compared to the non-PTSD control group, veterans with PTSD showed significantly greater punishment-based learning. Specifically, there was a significant Block × Group interaction, F(1, 54) = 4.12, p = .047, η(2) = .07. Veterans with PTSD demonstrated greater change in response bias for responding toward a less frequently punished stimulus across blocks. The observed hypersensitivity to punishment in individuals with PTSD may contribute to avoidant responses that are not specific to trauma cues.

A systematic review of written exposure therapy for the treatment of posttraumatic stress symptoms.

OBJECTIVE: Written exposure therapy (WET) is a brief treatment for posttraumatic stress disorder (PTSD), with an increasing number of studies published over the past several years. The current study conducted a systematic review to evaluate the current state of evidence for WET as a treatment for PTSD symptom severity. METHOD: Four databases were searched: PsycInfo, PTSDpubs, MEDLINE, and PubMed. Inclusion criteria included a peer-reviewed study of WET, a PTSD treatment outcome measure at pre- and posttreatment, and full-text available in English. RESULTS: Seventeen studies were identified for inclusion, seven of which were randomized controlled trials. Study sample sizes ranged from three to 277, with most studies (88%) examining adults. Five studies used a language translation version of WET, two studies examined a group format, and three studies examined PTSD symptom outcome when WET was delivered via telehealth. Within condition effect sizes for PTSD treatment outcome were moderate to large (d range = 0.48-6.45), and between condition effect sizes were large (d range = 1.05-5.25), except for three studies that included a trauma-focused treatment comparison condition (d range = 0.01-0.31). Dropout rates for WET were generally low, and less when compared with other trauma-focused treatments. CONCLUSIONS: The published studies indicate that WET is an efficacious and effective treatment for PTSD symptoms across a variety of samples, settings, and counties. Future work in this area should include investigation of the implementation and dissemination of WET. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Enhancing social functioning in older veterans with PTSD: Rationale and design of an intervention and initial RCT.

BACKGROUND: Older Veterans with Posttraumatic Stress Disorder (PTSD) are often socially isolated and have complex comorbid physical health problems. Aging-related stressors can exacerbate PTSD symptoms. These factors contribute to greater impairment in social functioning and decreased quality of life (QoL). Evidence-based psychotherapies for PTSD often address these issues, but not all older Veterans with PTSD seek help for these challenges, some don't want to engage in trauma-focused treatment, some drop out prematurely, and some still have residual symptoms upon completion. Thus, additional interventions that directly target social functioning among older Veterans with PTSD are needed. METHODS: In this paper we describe the development of and feasibility evaluation plan for, "Enhancing Social Functioning for older Veterans with PTSD (ESVP)," a social functioning group intervention for older (>60 years) Veterans with PTSD. This project involved four phases of work: 1) Intervention development, 2) Review of intervention and potential modifications using focus groups, 3) Intervention pilot testing and modification, and 4) A randomized feasibility trial comparing the intervention with a support group control. Intervention modules address interpersonal relationships, effective communication, anger management, social skills, social support/activities, and behavioral activation. CONCLUSION: This project details the iterative process used to develop the ESVP intervention designed to enhance social functioning in older Veterans with PTSD, and to evaluate feasibility. Analyses are underway to examine feasibility of conducting ESVP with a sample of older Veterans with PTSD. Findings from the final project phase, the randomized feasibly trial, will inform the design and implementation of a future trial. CLINICALTRIALS: gov Identifier: NCT02803125.

Reckoning With Our Past and Righting Our Future: Report From the Behavior Therapy Task Force on Sexual Orientation and Gender Identity/Expression Change Efforts (SOGIECEs).

Sexual orientation and gender identity/expression change efforts (SOGIECEs) are discredited practices that are associated with serious negative effects and incompatible with modern standards for clinical practice. Despite evidence linking SOGIECEs with serious iatrogenic effects, and despite support for LGBTQ+-affirmative care alternatives, SOGIECE practices persist. In the 1970s and 1980s, Behavior Therapy published articles testing and/or endorsing SOGIECEs, thereby contributing to their overall development, acceptance, and use. The Behavior Therapy Task Force on SOGIECEs was assembled to conduct a rigorous review of the SOGIECE articles published in Behavior Therapy and to decide whether, and what, formal action(s) should be taken on these articles. This report provides a detailed review of the historic SOGIECE literature published in Behavior Therapy and outlines the Task Force's deliberative and democratic processes resulting in actions to: (1) add prominent advisory information to k = 24 SOGIECE papers in the form of digital "black box" disclaimers that caution readers that the SOGIECE practices tested or described in these papers are inconsistent with modern standards, (2) offset organizational financial benefits from the publication of these papers, and (3) promote LGBTQ+-affirmative practices. SOGIECEs are not the only concerning practices across the field's history, and the pages of today's scientific journals include practices that will be at odds with tomorrow's moral standards and ethical guidelines. This report calls for precautionary measures and editorial safeguards to minimize the future likelihood and impact of problematic published scholarship, including the need to fully include those with relevant lived experiences in all aspects of clinical science and peer review.