The Role of Posttraumatic Growth in a Randomized Controlled Trial of Cognitive–Behavioral Conjoint Therapy for PTSD

Posttraumatic growth (PTG) is defined as a positive psychological change that can emerge following a traumatic life event. Although documented in noninterventional studies of traumatized individuals, there are scant data on the potential for therapy to induce or improve PTG. Thus, the primary goal of this study was to examine changes in PTG in a controlled trial of cognitive–behavioral conjoint therapy for posttraumatic stress disorder versus waitlist (CBCT for PTSD; Monson & Fredman, 2012). We also examined whether pretreatment relationship satisfaction and PTSD symptomatology moderated change in PTG. There were 40 couples (75% with a female partner with PTSD) who were randomized to either immediate CBCT for PTSD or a 3‐month waitlist (WL). Compared to WL, individuals who received treatment immediately demonstrated a significant increase in PTG. There was a moderate effect size between‐group difference (Hedge's g = 0.45). There was a nonsignificant relationship with a moderate effect size (Hedge's g = 0.65) for the positive effect of pretreatment relationship satisfaction on the trajectory of PTG, but no effect of pretreatment PTSD symptoms. Results suggested that CBCT for PTSD facilitated PTG, even with a limited focus on PTG in this conjoint intervention. Future research should target PTG as a treatment goal and further examine the role of close others in facilitating development of PTG.     

Couple Treatment for Alcohol Use Disorder and Posttraumatic Stress Disorder: Pilot Results From U.S. Military Veterans and Their Partners

We studied 13 U.S. male military veterans and their female partners who consented to participate in an uncontrolled trial of couple treatment for alcohol use disorder and posttraumatic stress disorder (CTAP). CTAP is a 15‐session, manualized therapy, integrating behavioral couples therapy for alcohol use disorder (AUD) with cognitive–behavioral conjoint therapy for posttraumatic stress disorder (PTSD). Due to ineligibility (n = 1) and attrition (n = 3), 9 couples completed the study, and 7 completed 12 or more sessions. There were 8 veterans who showed clinically reliable pre‐ to posttreatment reduction of PTSD outcomes. There were also significant group‐level reductions in clinician‐, veteran‐, and partner‐rated PTSD symptoms (d = 0.94 to 1.71). Most veterans showed clinically reliable reductions in percentage days of heavy drinking. Group‐level reduction in veterans’ percentage days of heavy drinking was significant (d = 1.01). There were 4 veterans and 3 partners with clinically reliable reductions in depression, and group‐level change was significant for veterans (d = 0.93) and partners (d = 1.06). On relationship satisfaction, 3 veterans and 4 partners had reliable improvements, and 2 veterans and 1 partner had reliable deterioration. Group‐level findings were nonsignificant for veteran relationship satisfaction (d = 0.26) and for partners (d = 0.52). These findings indicate that CTAP may be a promising intervention for individuals with comorbid PTSD and AUD who have relationship partners.     

Partner outcomes from an uncontrolled trial of Couple HOPES: A guided online couple intervention for posttraumatic stress disorder and relationship enhancement

Posttraumatic stress disorder (PTSD) is associated with significant individual and relationship impairment for people with PTSD and their romantic partners. Conjoint treatments, such as cognitive behavioral conjoint therapy for PTSD (CBCT), are designed to address individual and relationship factors, yet significant barriers impede accessing in-person therapy. Couple HOPES (i.e., Helping Overcome PTSD and Enhance Satisfaction) is a coach-guided, online couple intervention for PTSD based on CBCT that was designed to address these barriers. Previous investigations have found preliminary efficacy of Couple HOPES for improving PTSD symptoms, relationship functioning, and some individual functioning domains for the partner with probable PTSD. However, no study to date has tested individual outcomes for romantic partners, which is needed to fully evaluate the intervention's promise. The current study tested these partner outcomes in a combined, uncontrolled sample of 27 couples. Intent-to-intervene analyses found significant improvements at postintervention in four of eight tested outcomes, including ineffective arguing, g = 0.74; anger, g = 0.32; perceived health, g = 0.67; and quality of life, g = 0.56. Depressive symptoms, generalized anxiety, alcohol misuse, and work functioning did not significantly change, gs = 0.17–0.42. Among participants who completed a 1-month follow-up assessment, generalized anxiety, g = 0.43, and perceived health, g = 0.73, significantly improved over follow-up, whereas anger, g = -0.48, lost gains previously made. Results were largely consistent in the completer sample. These findings show the potential of Couple HOPES to have broad benefits not only for individuals with probable PTSD but also for their romantic partners.     

Prolonged Exposure and Sertraline Treatments for Posttraumatic Stress Disorder Also Improve Multiple Indicators of Social Functioning

Trauma survivors with posttraumatic stress disorder (PTSD) frequently also suffer from difficulties in social functioning that range across emotional, cognitive, and environmental domains. A detailed evaluation of the differential impacts of effective PTSD treatments on social functioning is needed. Men and women (N = 200) with chronic PTSD received 10 weeks of prolonged exposure (PE) or sertraline in a randomized clinical trial and were followed for 24 months. A secondary data analysis examined changes in social functioning with regard to fear of intimacy; receipt of social support; and distress, avoidance, and negative cognitions in social situations. Effects were examined between treatments over time, controlling for baseline functioning. There were large, durable improvements across all indices. Compared to sertraline, PE was more efficient at reducing fear of intimacy and distress from negative social cognitions by posttreatment, ds = 0.94–1.14. Patients who received sertraline continued to improve over the course of follow-up, ds = 0.54–1.17. The differential speed of therapeutic effects may argue for more direct mechanisms in cognitive behavioral interventions versus cascade effects in serotonin reuptake inhibitors. Notably, both treatments produced substantial social benefits for trauma survivors with social functioning difficulties, and effect sizes were comparable to typical reductions in PTSD, depression, and anxiety.     

A Randomized Controlled Study of Cognitive–Behavioral Therapy for Posttraumatic Stress in Street Children in Mexico City

The study aimed to evaluate cognitive–behavioral therapy (CBT) for posttraumatic stress (PTS), depression, anxiety, and anger in street children by a randomized controlled trial of CBT versus a waitlist control. It was conducted in 8 residential facilities for street children in Mexico City, with assessments at baseline, posttreatment, and 3 months later. Children who reported at least moderate posttraumatic stress, and fulfilled the study requirement were enrolled in the study (N = 100, 12–18 years old, 36 boys). There were 51 children randomized to CBT and 49 to the waitlist condition. Randomization was stratified by gender. CBT consisted of 12 individual 1‐hour sessions administered weekly by 2 trained, master's‐level clinicians. Outcome measures included self‐reports of PTS, depression, anxiety, and anger; global improvement was assessed by the independent evaluator. Compared to participants in the waitlist condition participants in CBT showed a significant reduction in all symptoms, with effects sizes of 1.73 to 1.75. At follow up there was attrition (n = 36), and no change from posttreatment scores. The study did find statistically significant improvement in symptoms in the CBT group compared to the waitlist condition; symptoms remained stable at 3 months. The study found that CBT for trauma in a sample of street children provided a reduction of a broad range of mental health symptoms.     

Treatment of comorbid posttraumatic stress disorder and major depressive disorder: a pilot study

The efficacy of a cognitive-behavioral treatment program for individuals with comorbid posttraumatic stress disorder (PTSD) and major depression (MDD) was examined. In an uncontrolled pre- and posttreatment study, participants attended 12-16 weeks of manualized therapy incorporating behavioral activation for depression in early sessions and exposure therapy and cognitive restructuring for PTSD in later sessions. Fourteen participants (of 20) completed treatment. Results indicated a significant decrease in PTSD and depression severity between pre- and midtreatment assessments; PTSD decreased further from mid- to posttreatment. Treatment gains were maintained at 3-month follow-up; 60% of participants no longer met PTSD criteria at 3-month follow-up, and 70% no longer met MDD criteria. The clinical implications of this phased approach to treat PTSD and depression comorbidity are discussed.     

Influence of Sleep Disturbance on Global Functioning After Posttraumatic Stress Disorder Treatment

Chronic insomnia and recurrent nightmares are prominent features of posttraumatic stress disorder (PTSD). Evidence from adult research indicates that these sleep disturbances do not respond as well to cognitive–behavioral therapies for PTSD and are associated with poorer functional outcomes. This study examined the effect of prolonged exposure therapy for adolescents versus client‐centered therapy on posttraumatic sleep disturbance, and the extent to which sleep symptoms impacted global functioning among adolescents with sexual abuse‐related PTSD. Participants included 61 adolescent girls seeking treatment at a rape crisis center. The Child PTSD Symptom Scale‐Interview (Foa, Johnson, Feeny, & Treadwell, 2001) was used to assess PTSD diagnosis and severity of symptoms, including insomnia and nightmares. The Children's Global Assessment Scale (Shaffer et al., 1983) was used to assess global functioning. There were significant main effects of time and treatment on insomnia symptoms. Additionally, there was a main effect of time on nightmares. Results also showed that insomnia and nightmares significantly predicted poorer global functioning posttreatment (R² = .21). Despite significant improvements in posttraumatic sleep disturbance, there were still clinically significant insomnia symptoms after treatment, suggesting that additional interventions may be warranted to address residual sleep disturbance in PTSD.     

Comparing Effectiveness of CPT to CPT‐C Among U.S. Veterans in an Interdisciplinary Residential PTSD/TBI Treatment Program

Cognitive processing therapy (CPT) is a leading cognitive–behavioral treatment for posttraumatic stress disorder (PTSD) and a front‐line intervention according to the U.S. Department of Veterans Affairs treatment guidelines. The original CPT protocol entails the creation of a written trauma account and use of cognitive therapy. Cognitive processing therapy–cognitive therapy only (CPT‐C) does not involve a written account and in a previous study resulted in faster symptom improvement and fewer dropouts than standard CPT. This study sought to replicate these findings by comparing the effectiveness of CPT to CPT‐C in a sample of 86 U.S. male veterans receiving treatment in a PTSD residential program for individuals with a history of traumatic brain injury. CPT and CPT‐C were delivered in a combined individual and group format as part of a comprehensive, interdisciplinary treatment program. Outcomes were self‐ and clinician‐reported PTSD and self‐reported depression symptoms. Multilevel analysis revealed no significant difference for PTSD symptoms, but did show a greater decrease in depression at posttreatment (d = 0.63) for those receiving CPT. When an experiment‐wise α correction was applied, this effect did not remain significant.     

The relationship between neurobehavioural problems of severe traumatic brain injury (TBI), family functioning and the psychological well-being of the spouse/caregiver: path model analysis

This study used a modern theory of stress as a framework to strengthen the understanding of the relationship between neurobehavioural problems of TBI, family functioning and psychological distress in spouse/caregivers. The research was an ex post facto design utilising a cross-sectional methodology. Path analysis was used to determine the structural effect of neurobehavioural problems on family functioning and psychological distress. Forty-seven female and 17 male spouse/caregivers of partners with severe TBI were recruited. Spouse/caregivers who reported partners with TBI as having high levels of behavioural and cognitive problems experienced high levels of unhealthy family functioning. High levels of unhealthy family functioning were related to high levels of distress in spouse/caregivers, as family functioning had a moderate influence on psychological distress. Furthermore, indirect effects of behavioural and cognitive problems operating through family functioning intensified the level of psychological distress experienced by spouse/caregivers. Additionally, spouse/caregivers who reported high levels of behavioural, communication and social problems in their partners also experienced high levels of psychological distress. This study was significant because the impact of TBI on the spouse/caregiver from a multidimensional perspective is an important and under-researched area in the brain injury and disability field.     

Clinical Manifestations of Trauma Exposure in Fibromyalgia: The Role of Anxiety in the Association Between Posttraumatic Stress Symptoms and Fibromyalgia Status

Little research has investigated how traumatic experiences relate to fibromyalgia (FM). We explored the presence of trauma exposure in a sample of Spanish participants with FM and examined the associations between (a) the number and type of traumatic experiences and posttraumatic stress disorder (PTSD) symptoms and (b) the severity of clinical manifestations in FM, testing for possible mediation models. Participants were 173 FM patients and 53 healthy controls aged 24 to 66 years. Traumatic event type (physical trauma, physical and sexual abuse, psychological trauma), PTSD symptoms, pain intensity, sleep disturbance, anxiety, depression, coping style, and daily functioning were evaluated via self-report. Fibromyalgia patients reported a higher percentage of trauma exposure than controls, more traumatic experiences (mainly emotional and physical trauma), and more PTSD symptoms, Hedges’ gs/Cohen's ds = 0.42–0.76. Most FM patients reported having experienced their most distressing traumatic experience and PTSD symptoms before FM diagnosis. PTSD symptom severity was associated with more pain, sleep disturbances, anxiety, depression, coping style, and functional impairment, rs = .23–.33, ps = .025–.008. A multiple mediation analysis showed a significant indirect effect of anxiety in the association between PTSD symptoms and daily functioning. In a subset of FM patients, PTSD symptoms were associated with major clinical symptoms. The results suggest future research should explore the effectiveness of trauma-focused therapy compared to standard cognitive behavioral therapy for these patients.     

The Quality of the Intimate Relationships of Male Vietnam Veterans: Problems Associated with Posttraumatic Stress Disorder

This study examined the quality of the intimate relationships of male Vietnam veterans. Heterosexual couples in which the veteran had posttraumatic stress disorder (PTSD; n = 26) were compared to couples in which the veteran did not have PTSD (n = 24). Over 70% of the PTSD veterans and their partners reported clinically significant levels of relationship distress compared to only about 30% of the non-PTSD couples. Relationship difficulties appeared to encompass a wide range of areas, with PTSD veterans and their partners reporting that they had more problems in their relationships, more difficulties with intimacy, and had taken more steps toward separation and divorce than the non-PTSD veterans and their partners. The degree of relationship distress was correlated with the severity of veterans' PTSD symptoms, particularly symptoms of emotional numbing. Research and clinical implications of the results are discussed.     

The impact of sudden gains in cognitive behavioral therapy for posttraumatic stress disorder

This study investigated sudden gains, i.e., rapid and stable improvements, in posttraumatic stress disorder (PTSD) symptoms that may occur in cognitive–behavioral therapy. Twenty‐nine of 72 participants (39.2%) experienced a sudden gain during treatment. Mixed model ANOVAs analyzed sudden gains impact on clinician‐rated PTSD symptom severity, patient‐rated PTSD symptom severity, and patient‐rated depressive symptom severity. Sudden gains in PTSD symptomology were associated with greater reductions in PTSD symptom severity for the avoidance/numbing and hyperarousal symptom clusters at posttreatment. By 6‐month follow‐up, the sudden gains group had maintained those reductions in symptoms, but the nonsudden gains group had achieved equal reductions in symptom severity. Participants experiencing sudden gains on PTSD measures had lower depression severity at posttreatment and follow‐up.     

A Dyadic Analysis of the Influence of Trauma Exposure and Posttraumatic Stress Disorder Severity on Intimate Partner Aggression

This study used structural equation modeling to evaluate a mediation model of the relationship between trauma exposure, posttraumatic stress disorder (PTSD) symptoms, and perpetration of intimate partner physical and psychological aggression in trauma‐exposed veterans and their cohabitating spouses (n = 286 couples; 88% male veteran and female spouse, 80.8% White, non‐Hispanic). Dyadic data analyses were used to simultaneously evaluate actor and partner effects using the actor–partner interdependence model (Kashy & Kenny, 2000). The primary hypothesis was that PTSD would mediate the association between trauma exposure and intimate partner physical and psychological aggression with these effects evident both within and across members of a couple (i.e., actor and partner effects). The best‐fitting model included (a) equivalent actor and partner direct effects of trauma on veterans’ acts of psychological aggression (β = .17 to .20, p = .001), and (b) equivalent actor and partner indirect effects via PTSD on veterans’ acts of physical aggression (β = .08 to .10, p < .001). There were no direct or indirect effects predicting the spouses’ aggression. Results suggest it is important to consider the trauma histories and possible presence of PTSD in both partners as this may be a point of intervention when treating distressed couples.     

Treatment outcome in Australian veterans with combat-related posttraumatic stress disorder: A cause for cautious optimism?

This study investigated treatment outcome in combat-related posttraumatic stress disorder (PTSD). Participants were 419 Australian Vietnam veterans who completed a 12-week hospital-based program. A comprehensive protocol assessed PTSD, comorbidity, and social functioning at admission and at 3 and 9 months posttreatment. Overall, the group showed significant improvements in core PTSD symptoms, anxiety, depression, alcohol abuse, social dysfunction, and anger. Changes occurred mostly between admission and 3 months posttreatment, with gains maintained at 9 months. Ratings by patients and their partners indicated perceived improvement and strong satisfaction with treatment. Nevertheless, treatment gains were variable and, for most veterans, considerable pathology remained following the programs. The current study provides grounds for cautious optimism in the treatment of combat-related PTSD.     

Treating Maladaptive Grief and Posttraumatic Stress Symptoms in Orphaned Children in Tanzania: Group‐Based Trauma‐Focused Cognitive–Behavioral Therapy

This study was designed to test the feasibility and child clinical outcomes for group‐based trauma‐focused cognitive behavior therapy (TF‐CBT) for orphaned children in Tanzania. There were 64 children with at least mild symptoms of grief and/or traumatic stress and their guardians who participated in this open trial. The TF‐CBT for Child Traumatic Grief protocol was adapted for use with a group, resulting in 12 weekly sessions for children and guardians separately with conjoint activities and 3 individual visits with child and guardian. Using a task‐sharing approach, the intervention was delivered by lay counselors with no prior mental health experience. Primary child outcomes assessed were symptoms of grief and posttraumatic stress (PTS); secondary outcomes included symptoms of depression and overall behavioral adjustment. All assessments were conducted pretreatment, posttreatment, and 3 and 12 months after the end of treatment. Results showed improved scores on all outcomes posttreatment, sustained at 3 and 12 months. Effect sizes (Cohen's d) for baseline to posttreatment were 1.36 for child reported grief symptoms, 1.87 for child‐reported PTS, and 1.15 for guardian report of child PTS.     

Effects of Psychotherapy on Trauma‐Related Cognitions in Posttraumatic Stress Disorder: A Meta‐Analysis

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders criteria for posttraumatic stress disorder (PTSD) incorporate trauma‐related cognitions. This adaptation of the criteria has consequences for the treatment of PTSD. Until now, comprehensive information about the effect of psychotherapy on trauma‐related cognitions has been lacking. Therefore, the goal of our meta‐analysis was to determine which psychotherapy most effectively reduces trauma‐related cognitions. Our literature search for randomized controlled trials resulted in 16 studies with data from 994 participants. We found significant effect sizes favoring trauma‐focused cognitive–behavioral therapy as compared to nonactive or active nontrauma‐focused control conditions of Hedges’ g = 1.21, 95% CI [0.69, 1.72], p < .001 and g = 0.36, 95% CI [0.09, 0.63], p = .009, respectively. Treatment conditions with elements of cognitive restructuring and treatment conditions with elements of exposure, but no cognitive restructuring reduced trauma‐related cognitions almost to the same degree. Treatments with cognitive restructuring had small advantages over treatments without cognitive restructuring. We concluded that trauma‐focused cognitive–behavioral therapy effectively reduces trauma‐related cognitions. Treatments comprising either combinations of cognitive restructuring and imaginal exposure and in vivo exposure, or imaginal exposure and in vivo exposure alone showed the largest effects.     

Posttraumatic Stress Disorder and Childhood Traumatic Loss: A Secondary Analysis of Symptom Severity and Treatment Outcome

Loss is a commonly experienced traumatic event among children. Although the experience of loss can potentially lead to posttraumatic stress symptoms (PTSS), little is known about PTSS levels after traumatic loss versus other traumatic events. We investigated data from a randomized controlled trial (RCT) on trauma-focused cognitive behavioral therapy (TF–CBT) versus a waitlist condition for children with PTSS. In a secondary analysis, we compared participants who reported traumatic loss as their index event (n = 23) to those who reported the two most frequently reported index events in the RCT: sexual abuse (SA; n = 59) and physical violence (PV; n = 55). The index event was rated according to the participants’ most distressing traumatic event reported on the Clinician-Administered PTSD Scale for Children and Adolescents. Participants who experienced traumatic loss reported fewer PTSS and better general functioning than those who reported SA. A subgroup RCT (n = 19) revealed TF–CBT to be highly effective in reducing PTSS in cases of traumatic loss, d = 1.69. The effect sizes for PTSS indicated that all three trauma groups benefited from TF–CBT. In the waitlist group, PTSS symptoms improved for SA and PV, ds = 0.76 and 0.98, respectively, but not for traumatic loss, d = 0.23. These findings suggest that TF–CBT is a feasible and promising treatment for children who experience PTSS after traumatic loss. The results are limited by the post hoc quality of the analyses and lack of a measure of grief in the RCT.     

The Effectiveness of Eye Movement Desensitization and Reprocessing Therapy to Treat Symptoms Following Trauma in Timor Leste

The effectiveness of eye movement desensitization and reprocessing (EMDR) therapy for treating trauma symptoms was examined in a postwar/conflict, developing nation, Timor Leste. Participants were 21 Timorese adults with symptoms of posttraumatic stress disorder (PTSD), assessed as those who scored ≥2 on the Harvard Trauma Questionnaire (HTQ). Participants were treated with EMDR therapy. Depression and anxiety symptoms were assessed using the Hopkins Symptom Checklist. Symptom changes post‐EMDR treatment were compared to a stabilization control intervention period in which participants served as their own waitlist control. Sessions were 60–90 mins. The average number of sessions was 4.15 (SD = 2.06). Despite difficulties providing treatment cross‐culturally (i.e., language barriers), EMDR therapy was followed by significant and large reductions in trauma symptoms (Cohen's d = 2.48), depression (d = 2.09), and anxiety (d = 1.77). At posttreatment, 20 (95.2%) participants scored below the HTQ PTSD cutoff of 2. Reliable reductions in trauma symptoms were reported by 18 participants (85.7%) posttreatment and 16 (76.2%) at 3‐month follow‐up. Symptoms did not improve during the control period. Findings support the use of EMDR therapy for treatment of adults with PTSD in a cross‐cultural, postwar/conflict setting, and suggest that structured trauma treatments can be applied in Timor Leste.     

The Impact of Hazardous Drinking Among Active Duty Military With Posttraumatic Stress Disorder: Does Cognitive Processing Therapy Format Matter?

This study was a secondary data analysis of clinical trial data collected from 268 active duty U.S. military service members seeking cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) at Fort Hood, Texas, related to combat operations following September 11, 2001. Our primary aim was to evaluate changes in PTSD symptom severity and alcohol misuse as a function of baseline hazardous drinking and treatment format (i.e., group or individual). At baseline and posttreatment, PTSD was assessed using the PTSD Symptom Scale–Interview Version and PTSD Checklist for DSM‐5. Hazardous drinking was categorically defined as an Alcohol Use Disorder Identification Test total score of 8 or higher. Employing intent‐to‐treat, mixed‐effects regression analysis, all groups reported reduced PTSD symptom severity, Hedges’ gs = ?0.33 to ?1.01, except, unexpectedly, nonhazardous drinkers who were randomized to group CPT, Hedges’ g = ?0.12. Hazardous drinkers who were randomized to individual therapy had larger reductions in PTSD symptoms than nonhazardous drinkers who were randomized to group CPT, Hedges’ g = ?0.25. Hazardous drinkers also reported significant reductions in alcohol misuse, regardless of treatment format, Hedges’ gs = ?0.78 to ?0.86. This study builds upon an emerging literature suggesting that individuals with PTSD and co‐occurring alcohol use disorder can engage successfully in CPT, which appears to be an appropriate treatment for these individuals whether it is delivered individually or in a group format. However, as a portion of participants remained classified as hazardous drinkers at posttreatment, some individuals may benefit from integrated treatment.