Characteristics of U.S. Veterans Who Begin and Complete Prolonged Exposure and Cognitive Processing Therapy for PTSD

New Study (1)Abstract

This retrospective chart-review study examined patient-level correlates of initiation and completion of evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) among treatment-seeking U.S. veterans. We identified all patients (N = 796) in a large Veterans Affairs PTSD and anxiety clinic who attended at least 1 individual psychotherapy appointment with 1 of 8 providers trained in EBP. Within this group, 91 patients (11.4%) began EBP (either Cognitive Processing Therapy or Prolonged Exposure) and 59 patients (7.9%) completed EBP. The medical records of all EBP patients (n = 91) and a provider-matched sample of patients who received another form of individual psychotherapy (n = 66) were reviewed by 4 independent raters. Logistic regression analyses revealed that Iraq and Afghanistan veterans were less likely to begin EBP than veterans from other service eras, OR = 0.48, 95% CI = [0.24, 0.94], and veterans who were service connected for PTSD were more likely than veterans without service connection to begin EBP, OR = 2.33, 95% CI = [1.09, 5.03]. Among those who began EBP, Iraq and Afghanistan veteran status, OR = 0.09, 95% CI = [0.03, 0.30], and a history of psychiatric inpatient hospitalization, OR = 0.13, 95% CI = [0.03, 0.54], were associated with decreased likelihood of EBP completion.


Mott, J.M., Mondragon, S., Hundt, N.E., Beason-Smith, M., Grady, R.H., & Teng, E.J. (2014).Characteristics of U.S. veterans who begin and complete prolonged exposure and cognitive processing therapy for PTSD. Journal of Traumatic Stress, 27(3), 265-273.doi: 10.1002/jts.21927.

Effects of Psychotherapy on Trauma-related Cognitions in Posttraumatic Stress Disorder: A Meta-Analysis

New Study (1)Abstract

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.


Diehle, J., Schmitt, K., Daams, J.G., Boer, F., & Lindauer, R.J. (2014). Effects of psychotherapy on trauma-related cognitions in posttraumatic stress disorder: a meta-analysis. Journal of  Traumatic Stress, 27(3), 257-264. doi: 10.1002/jts.21924.

Telephone-based CBT Improves PTSD Symptoms among Returning Veterans

Objectives: Many service members do not seek care for mental health and addiction problems, often with serious consequences for them, their families, and their communities. This study tested the effectiveness of a brief, telephone-based, cognitive-behavioral intervention designed to improve treatment engagement among returning service members who screened positive for posttraumatic stress disorder (PTSD).

Methods: Service members who had served in Operation Enduring Freedom or Operation Iraqi Freedom who screened positive for PTSD but had not engaged in PTSD treatment were recruited (N=300), randomly assigned to either control or intervention conditions, and administered a baseline interview. Intervention participants received a brief cognitive-behavioral therapy intervention; participants in the control condition had access to usual services. All participants received follow-up phone calls at months 1, 3, and 6 to assess symptoms and service utilization.

Results: Participants in both conditions had comparable rates of treatment engagement and PTSD symptom reduction over the course of the six-month trial, but receiving the telephone-based intervention accelerated service utilization (treatment engagement and number of sessions) and PTSD symptom reduction.

Conclusions: A one-time brief telephone intervention can engage service members in PTSD treatment earlier than conventional methods and can lead to immediate symptom reduction. There were no differences at longer-term follow-up, suggesting the need for additional intervention to build upon initial gains.

Stecker, T., McHugo, G., Xie, H., Whyman, K., & Jones, M. (2014). RCT of a Brief Phone-Based CBT Intervention to Improve PTSD Treatment Utilization by Returning Service Members. Psychiatric Services (washington, D.c), 65, 10, 1232-7.

Beliefs, Self-focus, and Behavior Related to PTSD

In a recent Beck Institute Workshop, Dr. Aaron Beck explains how negative beliefs, points of focus, and behavior play a role in the development of PTSD. He gives an example describing how one’s focus can lead to either an activation of negative beliefs or to adjustment.

Join us for our specialty workshop on CBT for PTSD. For more information visit our website.

Dissemination of Evidence-Based Treatments for PTSD: Barriers and Accomplishments

Posttraumatic stress disorder (PTSD) presents as a significant public health challenge because of its pervasive effects on mental health, physical health, and psychosocial problems. A recent review published in Psychological Science in the Public Interest, evaluates the effectiveness of prolonged exposure (PE) and cognitive behavior therapy (CBT) for individuals with PTSD. Although studies indicate that these treatments are efficacious for various populations, many individuals with PTSD do not receive evidence-based treatments (EBTs). The present review investigates barriers to be addressed in order to promote dissemination of EBTs for PTSD in developed and developing countries. Specifically, the authors review examples of dissemination models, discuss possible solutions, and suggest future steps in disseminating EBTs for PTSD. Improved dissemination of EBTs for PTSD is necessary in order to increase accessibility of successful treatments.

Foa, E. B., Gillihan, S. J., & Bryant, R. A. (2013). Challenges and successes in dissemination of evidence-based treatments for posttraumatic stress: Lessons learned from prolonged exposure therapy for PTSD. Psychological Science in the Public Interest, Supplement, 14(2), 65-111.

Pretreatment Predictors of Dropout in War Veterans Receiving CBT for PTSD

Although research suggests that cognitive behavior therapy (CBT) is rather efficacious in the treatment of posttraumatic stress disorder (PTSD) symptoms, CBT also appears to be limited by high rates of treatment attrition. A recent retrospective study published in Psychological Services examined differences between war veterans (Iraq and Afghanistan) who completed treatment versus those who dropped out of treatment.

Participants (N = 117) in the present study received outpatient CBT treatment for PTSD at a PTSD specialty clinic. Their clinical data was evaluated, and the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) was utilized to predict treatment dropout. Dropout was defined as ending treatment before attaining the predetermined treatment goals set by the client and clinician.

According to results, approximately 68% of participants dropped out of treatment. Younger war Veterans were more likely to drop out from treatment than older veterans. Additionally, patients with high scores on MMPI-2 TRT scale, which measure discomfort with discussing problems and negative attitudes toward mental health treatment, were also more likely to drop out of treatment. Notably, war veterans who completed treatment showed reductions in PTSD symptom severity. These results suggest that age and negative attitudes toward mental health services can help predict treatment adherence in war veterans seeking treatment for PTSD.

Garcia, H. A., Kelley, L. P., Rentz, T. O., & Lee, S. (February 01, 2011). Pretreatment Predictors of Dropout From Cognitive Behavioral Therapy for PTSD in Iraq and Afghanistan War Veterans. Psychological Services, 8, 1, 1-11.

Evidence-Based Treatment Approaches for Troops with PTSD

Nearly 20% of the 2.6 million troops deployed to Afghanistan and Iraq report symptoms of posttraumatic stress disorder (PTSD). PTSD is associated with hyperarousal, avoidance, and disturbing or reoccurring flashbacks, all of which affect mental and physical health.

The Department of Defense (DoD) and Veterans Affairs (VA) have recommend four treatment approaches for PTSD: Prolonged Exposure (PE) Therapy, Cognitive Processing Therapy (CPT), Stress Inoculation Therapy (SIT), and Eye-Movement Desensitization and Reprocessing (EMDR) Therapy. While there has been little empirical research indicating that EMDR and SIT are effective for PTSD, there is considerable research supporting the effectiveness of both PE and CPT. As a result, the VA has mandated that PE and CPT be available to all patients with PTSD. PE uses imagined and in vivo exposure to help patients confront trauma-related stimuli and extinguish fear responses. CPT targets trauma-related maladaptive cognitions by exposing patients to their own thoughts as they write about their traumas. According to the current review, four randomized control trials (RCTs) support the efficacy of PE for military-related PTSD and one RCT and one uncontrolled effectiveness study provide initial support for the efficacy of CPT in treating military-related PTSD.

Even though the VA has mandated PE and CPT for veterans and military service men and women with PTSD, it is important for clinicians who work with this population (both within and outside the VA) to educate their clients about evidenced based treatment to promote retention and recovery.

Steenkamp, M. M., & Litz, B. T. (February 01, 2013). Psychotherapy for military-related posttraumatic stress disorder: Review of the evidence. Clinical Psychology Review, 33, 1, 45-53.

CBT Helps Prevent Soldiers from Developing Symptoms of PTSD

Research indicates that 4.3% of troops develop PTSD upon returning from combat. A recent epidemiological study published by the Digital Access to Scholarship At Harvard describes a program launched by the Department of Veterans Affairs (VA) in an effort to reduce the risk for post-traumatic stress disorder (PTSD) in post-war veterans. This initiative ensures that all combat veterans, regardless of occupational rank, will receive evidence-based cognitive behavior therapy (CBT) upon returning from war.

In the current study, American, British, and Dutch authorities administered a number of epidemiological surveys to post-war veterans. These surveys were designed to evaluate the mental health status of veterans upon returning from the wars in Iraq and Afghanistan. Results of these surveys showed tense, irritable, and depressive-like symptoms among these soldiers, therefore making many of them candidates for CBT treatment. Participants in the study received either prolonged exposure (PE) treatment, which requires patients to recount traumatic memories repeatedly within a structured, supportive therapeutic context until distress declines, or cognitive processing therapy (CPT) which requires patients to write continuously about their traumatic experience. Of the 66% of veterans who completed the PE program, 74% had post-treatment scores that fell below the cutoff for PTSD.

Since this study, the Army has also developed a number of methods to prevent soldiers from developing symptoms for PTSD. One post-deployment early intervention program, Battlemind Debriefing, focuses on preparing soldiers with the specific skills they need to transition from combat zone to home. The Army has also developed similar training programs for larger groups transitioning from home to combat units. These programs teach soldiers “emotional bonding skills” that are useful to their specific combat unit. Rather than having soldiers focus on the traumatic events they have experienced, these programs focus on strengthening their family relationships and coping skills. According to the author, the prospects for resiliency and recovery from PTSD are at their current highest, as VA is ensuring evidence based treatment. Still, the “surest route to preventing PTSD in the world is to further the global decline in violence” (McNally, 13).

McNally, Richard J. (2013). Are we Winning the War Against Posttraumatic Stress Disorder? Digital Access to Scholarship at Harvard. Science 336 (6083). 1-16.

A Monthly Summary of Beck Institute Updates [June 2013]

In its efforts to encourage the growth and dissemination of CBT throughout the world, Beck Institute has expanded its online presence across social media and other platforms. To keep you (our readers) informed of our most recent updates, we’ve decided to implement a monthly summary including: blogs, CBT articles, CBT trainings, and other updates for our readers. We’re very excited about some of the new developments at Beck Institute, including our new Core Curriculum. Please use the following links to go back and read what you may have missed from June 2013:

Click here for a complete schedule of Beck Institute workshops

See what you missed in May 2013

A Monthly Summary of Beck Institute Updates [May 2013]

In its efforts to encourage the growth and dissemination of CBT throughout the world, Beck Institute has expanded its online presence across social media and other platforms. To keep you (our readers) informed of our most recent updates, we’ve decided to implement a monthly summary including: blogs, CBT articles, CBT trainings, and other updates for our readers. We’re very excited about some of the new developments at Beck Institute, including our new Core Curriculum. Please use the following links to go back and read what you may have missed from May 2013:

Click here for a complete schedule of Beck Institute workshops

See what you missed in April 2013