Effectiveness of Cognitive Processing Therapy for ...

Volume 36/N um ber 4/O ctober 2014/Pages 3 6 0 -3 7 6

Effectiveness o f Cognitive Processing Therapy fo r Treating Posttraumatic Stress D isorder S te p h e n L e n z B r ia n B ru ijn N in a S. S e r m a n L a u r a B a ile y

Analyzing 11 studies, we evaluated the effectiveness o f cognitive processing therapy (CPT) for treating posttraumatic stress disorder (PTSD) and co-occurring depression symptoms in individ uals diagnosed with PTSD. Separate meta-analytic procedures for between-group studies using waitlist or alternative treatment comparisons yielded large to very large effect sizes for CPT ver sus waitlist, and medium to large effect sizes when CPT was compared to alternative treatments. Implications for evidence-supported practice and study limitations are discussed.

Posttraumatic stress disorder (PTSD) is a clinical syndrome characterized by intrusive memories, emotional avoidance, and heightened physiologi cal arousal following exposure to a traumatic event (American Psychiatric Association [APA], 2000, 2013). The National Institute for Mental Health (2005) estimated that about 21 million individuals within the United States experience symptoms associated with PTSD; however, there is a burgeoning perception that prolonged military engagements may presage an increase in prevalence over the next decade (Hoge, Auchterlone, & Milliken, 2006; Schell & Marshall, 2008). Over the lifespan women report PTSD symptoms to a greater degree than men (Ditlevson & Elklit, 2010; Kessler et ah, 2005) and the degree to which an individual is exposed to deleterious influences, such as highly perilous vocations, partner violence, poverty, and lack of social support may heighten the risk for PTSD (Brewin, Andrews, & Valentine, 2000; Taylor & Baker, 2007). The prevalence of this syndrome across population subgroups is worrisome given that mood disorders like PTSD are among those most fre quently associated with disability (Social Security Administration, 2011) and lethality (Nepon, Belik, Bolton, & Sareen, 2010; Sabri et ah, 2013). W hen comparing individuals with PTSD to those without, researchers have identified a number of pervasive and detrimental trends, such as restricted peer relations (Laffaye, Cavella, Drescher, & Rosen, 2008); low academic

Stephen Lenz is a ffilia te d w ith Texas A & M University-Corpus Christi, and Brian Bruijn, N ina S. Serman, and Laura Bailey w ith The U niversity o f M em phis. Correspondence about this a rticle should be directed to A. Stephen Lenz, Texas A & M University-Corpus Christi, D e p a rtm e n t o f Counseling and E ducational Psychology, ECDC 152, Corpus Christi, Texas, 78412. Email: Stephen.Lenz@ tam ucc.edu.

360

0

Journal o f M en ta l H e a lth C o u nseling

Cognitive Processing Therapy and PTSD

achievement (Borofsky, Kellerman, Baucom, Oliver, & Margolin, 2013; Boyraz, Horne, Owens, & Armstrong, 2013); difficulty maintaining gainful employment (Kunst, 2011; Strauser, Lustig, Cogdal, & Uruk, 2006); hopeless ness and despondency (Hammock, Cooper, & Lezak, 2012; Pinna, Johnson, & Delahanty, 2013); and risk of self-injury (Gradus et al., 2010). Given its increasing prevalence (Hoge et al., 2006; Schell & Marshall, 2008) and its con sequences, it is prudent for counseling professionals to undertake interventions that promise better outcomes. When working with individuals diagnosed with PTSD, counselors often target decreasing the severity of (a) recurrent and intrusive distressing mem ories of the traumatic event, (b) emotional avoidance, and (c) heightened physiological arousal (Makinson & Young, 2012; Marotta, 2000). Outcomes may include decreasing aggressive outbursts, hypervigilance, and sleep distur bance that appeared or increased in intensity after exposure to the traumatic event (APA, 2013; Seligman & Reichenberg, 2012). Sledjeski, Speisman, and Dierker (2008) noted that in a sample of 9,282 randomly selected individuals, those meeting the criteria for PTSD were more likely to suffer from such co-occurring medical complications as chronic pain and cardiovascular, respiratory, and neurological conditions. Individuals diagnosed with PTSD who do present with these medical conditions tend to use medical services to a greater degree and have a markedly lower life expectancy (Deacon, Lickel, & Abramowitz, 2008). As a consequence, individuals with PTSD are susceptible to co-occur ring psychiatric conditions, notably major depressive disorder, substance abuse/ dependence, and bipolar disorder (APA, 2013; Spinazzola, Blaustein, & van de Kolk, 2005). Among co-occurring psychiatric disorders, some mental health profes sionals have suggested, depression may be most prevalent—and most lethal (Gradus et al., 2010; Hammock et al., 2012; Palgi, Ben-Ezra, Langer, & Essar, 2009; Pinna et al., 2013). Individuals with PTSD may be eight times more likely to attempt suicide than individuals without after controlling for comorbid major depressive disorder (Davidson, Hughes, Blazer, & George, 1991; Spinazzola et al., 2005). From this perspective, as the depression symptoms of individuals with PTSD become more severe, so too does the risk for selfharm. Given findings that individuals with PTSD and co-occurring depression symptoms report fewer treatment gains with antidepressant medications than those with depression alone (Green et al., 2006; Hollon et al., 2005), treat ment of co-occurring PTSD and depression may be further confounded. We submit that counseling interventions that concurrently mitigate the symptoms of PTSD and co-occurring depression may be the most practical for client treatment. Among strategies that have been proposed, cognitive processing therapy (CPT) has emerged as a viable option across treatment settings (Resick, Monson, & Chard, 2007; Zappert & Westrup, 2008).

361

COGNITIVE PROCESSING THERAPY

CPT, which was developed specifically to treat PTSD, integrates aspects of traditional cognitive therapy with information processing theory to restructure how to cope with and interpret a traumatic event (Resick et ah, 2007; Resick & Schnicke, 1993). To help clients gain control over intrusive symptoms, CPT counselors focus on how the secondary emotions and cog nitions that result from distorted interpretations about a traumatic event may affect future emotional processes and behaviors (Resick et ah, 2007; Resick & Schnicke, 1993). Secondary symptoms of PTSD include guilt, decreased quality of life, impairment of mental health, degree of social functioning, and health perceptions (Galovski, Blain, Mott, Elwood, & Houle, 2012). From a CPT perspective, Resick et al. suggested that PTSD symptoms epitomize a deviation from normal, inherent recovery processes, rather than being aberrant. Consequently, it is the role of the counselor to help clients identify irrational thoughts or avoidance behaviors that are interfering with healing. They pro posed that two factors sustain dysfunctional schemas about traumatic events that are maladaptive: (a) assimilation of information about the event into an existing schema that is inaccurate, distorted, and results in self-blame, and (b) over-accommodation of existing beliefs about the event that results in rigid and extreme thinking and behavioral patterns. CPT is based on the assumption that memories of an event need to be activated in the present so that fallacious attributions and expectations and related symptoms that interfere with their processing can be identified and replaced with corrective information (Resick & Schnicke, 1993). Although mitigating PTSD and co-occurring depression symptoms can be challenging, C PT counselors propose that two approaches can promote well-being for most clients: core skills associated with cognitive therapy and written trauma accounts. Integrating these into a strong working alliance creates a context that facilitates emotional processing of traumatic events via repeated exposure and a change in the meaning associated with them (Resick et al., 2008). Many CPT protocols (see Resick et ah, 2007; Resick et al., 2008; Resick & Schnicke, 1993) call for 12 clinical sessions during which the cognitive therapy compo nent predominates, with written trauma accounts in two sessions; homework assignments are individualized to help clients practice and process attitudes and actions learned in sessions. Sessions begin after intake and assessment and can be supplemented with sessions dealing with contributing factors, such as grief (Resick et ah, 2007). McHugh and Barlow (2010) noted that despite the common third-party mandate that counselors use evidence-based practices, for many treatments there is still a notable disconnect between counseling practice and supporting research. This is worrisome given the suggestion by some that aggregation and dissemination of outcome study findings have positive implications for regulat ing health care costs, facilitating reimbursement, and promoting the optimal well-being of clients (Lenz, 2013; McHugh & Barlow, 2010). With these inrpli-

362


cations in mind, we regard quantitative synthesis of outcome evidence related to using CPT to treat PTSD as a professional imperative. Traditional views of meta-analytic strategies support exclusive use of large samples of studies (e.g., k > 40), although contemporary researchers (Garg, Hackham, & Tonelli, 2008; Valentine, Pigott, & Rothstein, 2010) have emphasized the quality of study content and use of sensible analytic methods to accurately demonstrate treatment efficacy. Given the potential for CPT to ameliorate the medical, psychological, emotional, social, and financial effects of PTSD, it is worthwhile to consolidate the available outcome data. Although a number of studies have evaluated CPT treatment of PTSD, the results are rarely identical; a preliminary estimation of treatment efficacy might inform the practices of mental health counselors across settings when choosing treat ments. The purpose of this study was to evaluate the degree that CPT is effective for treating individuals diagnosed with PTSD and determine the degree to which it is a prudent treatment protocol. We completed a meta-analysis of out come studies published between 2000 and 2013 to answer two research ques tions: To what degree is CPT effective for decreasing the primary symptoms of PTSD? To what degree is CPT effective for treating the symptoms of comorbid depression of individuals being treated for PTSD? METHOD We identified quantitative studies that evaluated the effectiveness of CPT for treating the symptoms of PTSD and co-occurring depression, data from the studies were coded, consolidated, and synthesized using methods of controlling for varying sample sizes to provide an overall estimate of treatment effect for the target constructs. Inclusion and Exclusion Criteria Studies were included based on the following criteria: • Researchers implemented a between-groups quantitative research design. • Participants were treated for symptoms of PTSD as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision. • Eligibility was formally assessed by a trained mental health practitioner. • CPT was identified as the primary therapeutic strategy for reducing PTSD symptoms. • Participants completed standardized assessments before treatment (pre test) and at termination (posttest).

363

• Mean and standard deviation data for pretest and posttest measures were adequate to permit calculation of standardized mean difference effect sizes. • Studies were published in English. Studies excluded from the analysis were those that made causal inferences based on single-group, single-case, or correlational research designs; did not include pretest data; did not include participant demographic information; were not published in peer-reviewed periodicals; and were book chapters, dissertations, theses, or gray literature. Data reported in multiple publications were also not included. These decisions were made a priori to control for the quality of the findings to be synthesized and the presence of confounding vari ables related to estimation of CPT treatment effect. Search Strategies To identify and include all relevant empirical content that presented materia] related to the treatment of PTSD symptoms and co-occurring depression among individuals with PTSD, we implemented three search strategies: (a) electronic database searches, (b) journal-specific searches, and (c) review of reference lists. The second and third authors separately searched the PsycINFO, JStor, Pubmed, Academic OneFile, Web of Science, PsycARTICLES, and SciVerse databases for 2000 through 2013. Keywords used to identify the intervention were Cognitive Processing Therapy and Processing; terms used to identify the intended population were Trauma, Posttraumatic, and PTSD. All items retrieved were screened through the databases’ peer-reviewed function to yield relevant abstracts. Journal-specific searches were then completed to identify eligible studies in Behavior Therapy, Journal of Counseling and Development, Counseling Outcome Research and Evaluation, Journal of Mental Health Counseling, Journal of Consulting and Clinical Psychology, Cognitive and Behavioral Practice, Journal of Trauma Practice, Journal of Traumatic Stress, Journal of Cognitive Psychotherapy, The Counseling Psychologist, Psychological Trauma: Theory, Research, Practice, and Policy, and Journal of Aggression, Maltreatment, and Trauma. Finally, reference lists within eligible articles and CPT treatment manuals were reviewed to iden tify any other studies eligible for inclusion. All articles and abstracts that met the inclusion criteria were consolidated using the RefWorks database software program (www.refworks.com) and file redundancies were eliminated using the check duplicates function. Coding Procedures The second and third authors separately coded each of the studies chosen according to guidelines presented by Cooper, Hedges, and Valentine (2009) and Lipsey and Wilson (2001), including source descriptors and characteristics related to sample, research methodology, treatments administered, measure ment, data analysis, and study outcome. Both coders were graduate students

364


(one master’s, one doctoral) in a department accredited by the Council for Accreditation of Counseling and Related Educational Programs and the American Psychological Association; both had completed advanced coursework in research methods, statistics, and assessment and were given an ori entation to evidence-based practices, meta-analytic procedures, and training, with subsequent supervision using a coding manual drafted by the first author. Any discrepancies detected between coders were scrutinized, discussed, and resolved through consultation with the first author.

Outcome Measures The dependent variables of interest in this analysis were severity of PTSD and depression symptoms. Effect sizes evaluating therapeutic change in PTSD symptoms were computed for most of the studies used self-report measures (n = 11 of 13; 84%), with only two studies providing only clinician-administered outcome measures. All effect sizes estimating therapeutic change for depres sion symptoms used self-report measures.

Statistical Methods Several authors have indicated the importance of applying separate met rics for types of between-group studies (Cooper et al., 2009; Lipsey & Wilson, 2001) and recommended that these be synthesized and reported distinctly. For all studies, we computed standardized mean difference effect sizes for each outcome variable and transformed values using Hedge’s g to account for bias associated with sample size and sampling error. The related standard error estimates, inverse variance weights, and confidence intervals were computed at the 95% level to evaluate the null hypothesis using the procedure described by Lipsey and Wilson. This process resulted in two groups of effect sizes (treat ment vs. control; treatment vs. alternative treatment) for both of the outcome variables of interest (PTSD and depression symptoms). Mean effect size for each group of studies was computed as the proportion of summed effect sizes, weighted by the inverse of their sampling error vari ance, divided by the sum of effect size weights (see Lipsey & Wilson, 2001). For each mean effect size, standard error was estimated using related inverse variance weights and summed effect size weights. Next, confidence intervals surrounding mean effect sizes were computed at the 95% level to evaluate whether the null hypothesis evaluating treatment effectiveness could be reason ably rejected. To address publication bias, funnel plots were evaluated and fail safe N (Nj) was computed. Funnel plots illustrating symmetrical distributions of effect sizes across study sample sizes indicate judicious reporting; funnel plots that are skewed indicate reporting bias. The fail-safe N metric estimates the number of unpublished studies reporting no treatment effect needed to negate findings. When N f is strikingly low, it is plausible that reported mean effect sizes are biased and not characteristic of actual treatment effectiveness. Analysis of homogeneity and moderating variables. The assumption of homogeneity of effect size distributions was analyzed by calculating Cochran’s

365

Q statistic using the protocol identified by Lipsey and Wilson (2001). All values for Q were referenced with chi-square critical values to test the homogeneity hypothesis at the .05 level. When the Q values are significant (i.e., p < .05), heterogeneity is assumed and moderator variables should be evaluated (Cooper et ah, 2009; Lipsey & Wilson, 2001). Evaluation of moderating variables in large sample meta-analyses generally relies on weighted least squares regression analyses (Lipsey & Wilson, 2001); however, smaller samples like ours may be subject to visual scrutiny of apparent differences between study attributes that may contribute to differences in individual effect sizes. RESULTS Of the 193 articles selected for scrutiny through the inclusion/exclusion criteria, 11 were analyzed; Table 1 illustrates representative summary data. The total number of participants across studies was 919 and for all studies participants were predominantly adults (n = 881; 95%) who were women (n = 530; 58%); in studies that reported ethnicity data (n = 10) the majority of participants were Caucasian (n = 571 of 821; 69%). Eight of the studies were composed of individuals in the United States and three were international (Forbes et al., 2012; Hinton et ah, 2004; Nixon, 2012). Reported treatment time for clients ranged from 6 to 17 sessions. The majority of studies (n = 9 of 11; 81%) evaluated CPT using manual-based treatment approaches; all the studies coded indicated that treatments were facilitated by practitioners who had received training and supervision in CPT. Of the 11 studies, 9 were con ducted in an outpatient setting and two at inpatient facilities. We evaluated the effectiveness of CPT for decreasing the severity of PTSD and co-occurring depression symptoms using a sample of 11 studies (4 waitlist, 6 alternative treatment, 1 both waitlist and alternative treatment). To gain a clearer understanding of CPT effectiveness, separate mean effect sizes were computed for waitlist and alternative treatment studies and interpreted using guidelines suggested by Cohen (1988) for describing magnitudes of effect sizes as small (d > .20), medium (d a .50), and large (d a .80). Does CPT Decrease the Seventy o f PTSD Symptoms?

CPT versus waitlist studies. The five studies included in the analysis of CPT versus waitlist (n = 262) yielded a mean effect size of 1.79, which indi cates a very large treatment effect; the confidence interval above zero (CI95 = 1.50-2.08) suggests that the null hypothesis can be rejected (see table 2). This sample yielded an Nyof 897, indicating that 897 unpublished studies witii an effect size of zero would be needed to negate our findings. In examining homogeneity we found that the results, Q(4) = 22.39, p. < .05, were significant and warranted inspection for moderator variables. Among the five studies com prising this sample, there was considerable variability of effect sizes associated with population age and type of trauma. Two that reported lower effect sizes were associated with treatment of adolescents (Ahrens & Rexford, 2002) or older adults (Monson et ah, 2006); the three studies completed with samples. 366


Table I . Characteristics of Studies Used in the Meta-Analysis Study

Sum m ary

N

A g e (M )

Ahrens & Rexford (2002)

Evaluated an 8-session, manualbased C PT treatment presented in group format

38

16.2

Resick et al. (2002)

Compared 12-session manual-based C PT to prolonged exposure and minimal attention

121

32

Hinton et al. (2004)

Evaluated an 11-session C PT treatment that

12

Sam ple

Ethnicity

C o ntrol Type

Caucasian (n = 23); African American {n = 10); Hispanic (n = 2); Native American (n = 2); Other (« = 1 )

Waitlist

W om en with sexual assault history in an outpatient setting

Caucasian (n = 86); African American {n = 30); Other (n = 5)

Waitlist & Alternative treatment

**

Men w ho were refugees in outpatient clinic

Vietnamese (N = 12)

Waitlist

W omen with sexual assault history at a university clinic

Caucasian (n = 0); African American {n = 12); Hispanic (n = 3)

Waitlist

Boys who w ere incarcerated

integrated mindfulness Chard (2005)

Evaluated a 17-week manual-based CPT treatment in group and individual formats

71

32.77

Nishith, Nixon, & Resick (2005)

Compared 12-session manual-based C P T to prolonged exposure

98

33

W omen with sexual assault history in an outpatient setting

**

Monson et al. (2006)

Compared a 12-session, manual-based C PT intervention to waitlist

60

54

W omen (n = 6) & men (n = 54) military veterans

Caucasian (n = 56); Other ( n = 4)

Waitlist


Compared 12-session, manual-based C P T to cognitive therapy or writing assignment

147

35.4

W omen who w ere victims of abuse in an outpatient setting

Caucasian (n = 93); African American (w = 51); Other (« = 3)

Alternative treatment

Alvarez, McLean, Harris, Rosen, & Ruzek (2011)

Compared 14-session, manual-based C PT to a trauma-focused group

197

52.23

Men who were veterans in a residential setting

Caucasian^ =117); Other {n = 80)


Forbes et al. (2012)

Compared 12-sesion, manual-based C PT to eclectic TAU

59

53.37

Men who w ere veterans of the Australian military

Caucasian (N = 59)


Nixon (2012)

Compared 6-session C PT to supportive counseling

30

40.64

W omen (n = 14) and men (n = 16) at university clinic

Caucasian ( n = 29); Aboriginal (n = 1)


Suris et al. (2013)

Compared 12-session, manual-based CPT to 12 sessions of present-centered therapy

86

46

W omen (n = 73) and men (n = 13) who experienced military sexual trauma

Caucasian (n = 38); African American (n = 35); O ther ( « = 13)



367

T a b le 2 . T r e a t m e n t E ffe c t S ize s a n d 9 5 % C o n fid e n c e In te r v a ls f o r S tu d ie s E v a lu a tin g C o g n itiv e P ro c e ss in g T h e r a p y E ffe ctive n es s f o r D e c r e a s in g P T S D S y m p to m S e v e r ity using C o n tr o l a n d A lt e r n a t i v e T r e a t m e n t G ro u p s

E ffe c t S iz e W e ig h t

S tu d y

Ahrens & Rexford (2002)

15%

1.19 [.50, 1.88]


31%

2.65 [2.05, 3.25]

Hinton et al. (2004)

5%

2.20 [.77,3.63]

Chard (2005)

26%

2.31 [1.71,2.91]

Monson et al. (2006)

23%

1.00 [.46, 1.54]

M e a n E ffe c t S iz e

C P T vs. C o n tr o l G r o u p

w ith 9 5 % C l

1.79 [1.50,2.08] - 1

0

1

2

3

4

E ffe c t S iz e W e ig h t

S tu d y


11%

.41 [-.03, .85]

Nishith et al. (2005)

7%

.25 [-.28, .78]

Nishith et al. (2005)

6%

.18 [-.42, .78]


13%

.16 [-.23, .55]


13%

.08 [-.32, .48]

Alvarez et al. (2012)

26%

.56 [.27, .85]

Forbes et al. (2012)

8%

.56 [.04, 1.08]

Nixon (2012)

5%

1.50 [.69,2.31]

Suris et al. (2013)

11%

3.06 [2.43,3.69]


C P T vs. A lt e r n a t i v e T r e a tm e n ts

w it h 9 5 % C l

.62 [.47, .77] - 1

0

1

2

3

4

of young adults yielded comparable treatment results. Furthermore, the studies reporting lower effect sizes were composed of individuals receiving treatment associated with being incarcerated (Ahrens & Rexford) or completing military combat duty (Monson et al.). In contrast, the other three studies were com posed of individuals who had been victims of sexual assault (Chard, 2005; Resick, Nishith, Weaver, Astin, & Feuer, 2002) or displaced from their homes after a crisis (Hinton et al., 2004). We therefore conjecture that the heteroge-

368


neity in effect-size distributions may be associated with the age of participants and the type of trauma being treated. CPT versus alternative treatments. The seven studies covered in the analysis of CPT versus alternative treatment (n = 751) yielded a mean effect size of .62, which indicates a medium treatment effect, and the confidence interval above zero (CI95 = AT-.11) suggests that the null hypothesis can be rejected (see table 3). This sample yielded an Nyrof 561, indicating that 561 unpublished studies with an effect size of zero would be needed to negate our findings. In examining homogeneity we found that the results, Q(8) = 111.77, p < .05, were significant and justified examination for moderator variables. Analysis of study characteristics indicated that among the 7 studies and 9 effect sizes comprising this sample, the marked variability of effect sizes was associ ated with the type of alternative treatment provided to participants. Although the majority of individual effect sizes contributing to the mean were affiliated with studies using variations of cognitive therapy or exposure tasks, two studies that reported notably higher effect sizes (Nixon, 2012; Suris, Link-Malcom, Chard, Ahn, & North, 2013) compared CPT with supportive, nondirective approaches to counseling. Although these studies were only 16% of the weight for the mean effect sizes, it is possible that this characteristic influenced mean differences beyond sampling error. Can CPT Decrease the Severity o f Co-occurring Depression Symptoms? CPT versus waitlist. The five samples that were analyzed for CPT versus waitlist (n = 262) yielded a mean effect size of 1.68, which indicates a very large treatment effect, and the confidence interval above zero (CI95 = 1.40-1.96) suggests that the null hypothesis can be rejected (see table 2). Since this sample yielded an Nf of 840, it would take 840 unpublished studies with an effect size of zero to refute our findings. In examining homogeneity of effect sizes, we found that the results, Q(4) = 6.33, p > .05, were not significant and did not warrant inspection for moderator variables. CPT versus alternative treatment. The seven samples that were analyzed for CPT versus alternative treatment (n = 751) yielded a mean effect size of .46, which indicates a medium treatment effect, and the confidence interval above zero (CI95 = .31—.61) suggests that the null hypothesis can be rejected. This sample yielded an N r of 415, indicating that 415 unpublished studies with an effect size of zero would be needed to disaffirm our findings. In examining homogeneity we found that the results, Q(8) = 28.64, p < .05, were significant and justified examination for moderator variables. As with PTSD symptom severity, analysis found that among the 7 studies and 9 effect sizes comprising this sample, the marked variability of effect sizes was associated with the type of alternative treatment. Comparisons to CPT made by Nixon (2012) and Suris et al. (2013) implemented supportive, nondirective interventions and were associ ated with more disparate treatment effects than studies of cognitive or exposure therapies. Although these studies contributed just 16% of the mean effect size

369

T a b le 3 . T r e a t m e n t E ffe c t S ize s a n d 9 5 % C o n fid e n c e In te r v a ls f o r S tu d ie s E v a lu a tin g C o g n itiv e P ro c e s s in g T h e r a p y f o r C o -o c c u r r in g D e p re s s io n u sin g C o n tr o l G ro u p s a n d A lt e r n a t i v e T r e a t m e n t C o n d itio n s

E ffe c t S ize S tu d y

W e ig h t

w ith 9 5 % C l

S tu d y

W e ig h t

w it h 9 5 % C l

C P T vs. C o n tr o l G r o u p

E ffe c t S ize

Resick etal. (2002)

11%

.55 [.II,.99]

Nishithetal. (2005)

7%

.15 [-.38, .68]

Nishithetal. (2005)

6%

.48 [-.13, 1.09]


13%

.11 [-.28, .50]


13%

.29 [-.II,.69]

Alvarez et al. (2012)

26%

.33 [.05, .61]

Forbes etal. (2012)

8%

.40 [-.12, .92]

Nixon (2012)

5%

1.88 [1.02, 2.74]

Suris et al. (2013)

11%

1.22 [.75, 1.69]


C P T vs. A lt e r n a t i v e T r e a tm e n ts

.46 [.31,.61] - 1

0

1

2

3

4

weight, we believe that this characteristic influenced mean differences not associated with sampling error. DISCUSSION This meta-analysis yielded some suggestive findings. In the 11 studies located, mean effect sizes yielded for treating PTSD symptoms were note worthy regardless of comparison group type (waitlist or alternative treatment).

370


This finding is promising for some clients considering that unremitted PTSD symptoms are closely associated with disability status (Social Security Administration, 2011) and lethality (Nepon et ah, 2010; Sabri et al., 2013). Further, counselors deciding to use CPT with clients meeting PTSD criteria will be able to provide an intervention that may protect against deleterious psychosocial outcomes, such as decreased peer relations (Laffaye et al., 2008); low academic completion (Borofsky et al., 2013; Boyraz et al., 2013); and dif ficulty retaining gainful employment (Kunst, 2011; Strauser et al., 2006). It is reasonable to infer that clients who can avoid these problems may be less likely to develop other psychiatric disorders, such as resultant major depressive dis order or social phobia. Therefore, our preliminary findings provide empirical support for CPT as a treatment choice when reporting to third-party payers, stakeholders, or funding agencies. The analysis of whether CPT interventions decrease the severity of co-occurring depression symptoms among individuals with PTSD revealed medium to large treatment effects. This finding is promising given the supposition of some (APA, 2013; Gradus et al., 2010) that individuals with PTSD are at increased risk for self-injury. It is reasonable to suppose that using CPT to lessen the severity of co-occurring depression symptoms may lessen the rates of self-injurious behaviors and lethality among clients with PTSD. This finding is especially encouraging given that individuals who have both PTSD and depression may be less responsive to medication than those with depression alone (Green et al., 2006; Hollon et al., 2005).

Using Evidence-Supported Treatments Although our findings are limited to consolidation of 11 studies, we believe our results provide substantiation for CPT as an evidence-supported treatment for PTSD. Review of benchmarks established by Chambless et al. (1996, 1998) for qualifying counseling interventions as well-established, moderately efficacious, or unsupported indicate that the synthesized findings of at least two between-groups studies are required to make inferences about treatment efficacy. Chambless and colleagues suggested that statements about causal inference are most prudent when data are associated with studies that had at least one comparison group and reasonable experimental controls, such as randomization, manualized interventions, and participants with similar diag nostic characteristics. The between-groups studies in our analyses (N = 11) met the criteria for number of studies needed and standards for experimental rigor to merit preliminary evidentiary support. We submit that reference to findings of meta-analyses of between-groups studies is imperative for counseling profes sionals working with individuals diagnosed with PTSD who are obligated to justify treatment protocols to clients and stakeholders. Several authors have described the importance of counselors using interventions that have evidentiary support for their target population to pro mote accountability to third- party payers (Cooper & Hedges, 2009; Lipsey & Wilson, 2000). Since the majority of participants in the studies we evaluated

371

were Caucasian (69%), it is reasonable to infer that our results may be most rel evant for other Caucasian clients. This may be a limitation counselors should consider when selecting an intervention for clients with PTSD; however, sev eral ethnic groups were represented in individual studies that contributed to mean effect sizes that can be inspected when making clinical decisions. With these caveats in mind, together the findings of our analyses and the contribut ing studies may support counselors who need evidentiary support for services provided across treatment settings. It is also conceivable that corroboration of our findings through replication studies might provide impetus for counselors advocating for endorsement of using CPT to treat PTSD and changes to the policies, standards, and practices of insurance companies, mental health agen cies, and training programs. Increased awareness and the growth of care strate gies available to counselors may improve the welfare and relational functioning of clients seeking treatment for PTSD. Limitations and Suggestions for Future Research Although this study found some encouraging implications for counsel ing professionals, there are some caveats: Because only a small number of between-groups studies were published between 2000 and 2013 (see table 1), only 11 were located for analysis. Although these were between-groups designs with controls to promote rigor and experimental validity, the small number of studies analyzed may limit findings when compared to larger studies (k > 20). Furthermore, although the study samples were relatively homogeneous, sample sizes varied greatly, leaving some populations outside the realm of generalizability. Because our sample of studies was limited to those with systematic designs to protect against the garbage in, garbage out critique of some larger meta-analyses, we suggest that our findings be regarded as an intermediary between single studies and a more fully developed conceptualization of CPT treatment effectiveness. We also acknowledge that without individual studies evaluating CPT with individuals who have PTSD, more definite findings of treatment effectiveness will not be possible. O f particular interest would be studies that compare CPT to a number of alternative treatments to allow for distinct comparisons. The limited number of studies available for consideration demonstrates the need for more comprehensive research studies that implement experimental and quasi-experimental between-groups research methodologies. Our analysis looked at CPT effectiveness for the target outcomes because clients received treatment and at termination. Although these intervals are both common and practical for counselors to assess progress, more inferences about long-term effectiveness might have been garnered through follow-up measure ments at a sensible interval after termination. Our results were also limited in the inferences related to the age groups or trauma etiologies most responsive to CPT treatment. For instance, CPT may well be more effective for adult clients than for children, given the level of cognitive differentiation required for many cognitive therapies. Likewise, recent trauma experiences may be more amena ble to remediation than chronic experiences over time that are associated with

372


more crystalized schemas about causality and guilt. Such factors may best be accounted for in future research by using cross-sectional methodologies. Finally, our analysis did not include some studies because descriptive and statistical information was under-reported. We encourage future researchers to accurately describe participant characteristics and statistical findings using the guidelines in the Publication Manual of the American Psychological Association (American Psychological Association, 2010) to assure that specific demographic frequencies, means and standard deviations for scores, and details about treatment interventions are available to future researchers attempting to make inferences and causal attributions related to treatment efficacy. CONCLUSION

The growing prevalence of PTSD has foreboding consequences for indi viduals across psychosocial domains. Without sufficient treatment, individuals are vulnerable to a number of well-being disparities that may result in co-oc curring psychiatric symptoms, disability status, or self-injury or fatality. This study produced some telling, but preliminary, findings that support the use of manual-based CPT protocols administered by trained mental health profes sionals for treating PTSD and co-occurring depression. The small sample of studies synthesized here, we submit, is illustrative of studies published within a 14-year range that met criteria for rigor and design that allow for causal infer ences about treatment efficacy. Further attributions related to CPT as an evi dence-supported intervention for the treatment of PTSD are contingent upon new findings from scientist-practitioners working with this target population. In particular, studies that compare the effectiveness of CPT with that of alterna tive treatments or that deconstruct components of CPT to identify which are most influential across diverse populations are encouraged. REFERENCES Ahrens, ]., & Rexford, L. (2002). Cognitive processing therapy for incarcerated adolescents with P TSD . journal o f Aggression, Maltreatment and Trauma, 6,201—216. doi: 10.1300/J lT6v06n01_10 Alvarez, McLean, C., Harris, A., Rosen, C., & Ruzek, J. (2011). The comparative effectiveness of cognitive processing therapy for male veterans treated in a VHA posttraumatic stress disorder residential rehabilitation program, journal o f Consulting and Clinical Psychology, 79, 590-599. doi: 10.1037/a0024466 American Psychiatric Association. (2000). Diagnostic and statistical manual o f mental disorders (4th ed., text rev.). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual o f mental disorders-S. (5th ed.). Washington, DC: Author. American Psychological Association, (2010). Publication manual o f the American Psychological Association (6th ed.). Washington, D.C.: American Psychological Association. Borofsky, L., Kellerman, I., Baucom, B., Oliver, P., & Margolin, G. (2013). Community violence exposure and adolescents’ school engagement and academic achievement over time. Psychology ofViolence, 3, 381-395. doi:10.1037/a0034121 Boyraz, G., Horne, S. G., Owens, A. C., & Armstrong, A. P. (2013). Academic achievement and college persistence of African American students with trauma exposure, journal o f Counseling Psychology, 60, 582-592. doi:10.1037/a0033672

373

Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68, 748766. doi: 10.1037//0022-006X.68.5.748 Chambless, D. L., Baker, M. J., Baucom, D. H., Beutler, L. E., Calhoun, K. S., Crits-Christoph, P.,.. .Woody, S. R. (1998). Update on empirically validated therapies, II. The Clinical Psychologist, 51,3-16. Chambless, D. L., Sanderson, W. C., Shoham, V., Bennett Johnson, S., Pope, K. S., CritsChristoph, P.,.. .McCurry, S. (1996). An update on empirically validated therapies. The Clinical Psychologist, 49, 5-18. Chard, K. M. (2005). An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. Journal o f Consulting and Clinical Psychology, 73, 965-971. doi: 10.1037/0022-006X.73.5.965 Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Mahwah, NJ: Lawrence Erlbaum. Cooper, H., & Hedges, L. (2009). Research synthesis as a scientific process. In H. Hedges, L. Hedges, & J. Valentine, The handbook o f research synthesis and meta-analysis (pp. 1-16). New York, NY: Russell Sage Foundation. Cooper, H., Hedges, L., & Valentine, J. C (2009). The handbook o f research synthesis and meta analysis. New York, NY: Russell Sage Foundation. Davidson, J., Hughes, D., Blazer, D., & George, L. (1991). Post-traumatic stress disorder in the community: Air epidemiological study. Psychological Medicine, 21, 713-721. doi: 10.1017/ S0033291700022352 Deacon, B., Lickel, J., & Abramowitz, J. (2008). Medical utilization across the anxiety disorders. Anxiety Disorders, 22, 344-350. doi:10.1016/j.janxdis.2007.03.004 Ditlevson, D. N., & Elklit, A. (2010). The combined effect of gender and age on posttraumatic stress disorder: Do men and women show differences in the lifespan distribution of the disorder? Annals o f General Psychiatry, 9, 32-44. doi: 10.1186/1744-859X-9-32 Forbes, D., Lloyd, D., Nixon, R. D. V., Elliott, P., Varker, T., Perry, D.,...Cream er, M. (2012). A multisite randomized controlled effectiveness trial of cognitive processing therapy for militaryrelated posttraumatic stress disorder. Journal o f Anxiety Disorders, 26, 442—452. doi: 10.1016/j. janxdis.2012.01.006 Galovski, T. E., Blain, L. M., Mott, J. M., Elwood, L., & Houle, T. (2012). Manualized therapy for PTSD: Flexing the structure of cognitive processing therapy. Journal o f Consulting and Clinical Psychology, 8 0 ,968-981. doi: 10.1037/a0030600 Garg, A.X., Hackam D., & Tonelli M. (2008). Systematic review and meta-analysis: W hen one study is just not enough. Clinical Journal o f the American Society o f Nephrology, 3, 253-260. Gradus, J., Qin, P., Lincoln, A., Miller, M., Lawler, E., Sprensen, H., & Lash, T. (2010). Posttraumatic stress disorder and completed suicide. American Journal o f Epidemiology, 171, 721-727. doi: 10.1093/aje/kwp456 Green, B., Krupnick, J., Chung, J., Siddique, J., Krause, E., Revicki, D .,...M iranda, J. (2006). Impact of PTSD comorbidity on one-year outcomes in a depression trial. Journal o f Clinical Psychology, 62, 815-835. doi:10.1001/jama.295.9.1023 Hammock, S., Cooper, M., & Lezak, K. (2012). Overlapping neurobiology of learned helplessness and conditioned defeat: Implications for PTSD and mood disorders. Neuropharmacology, 62, 565-575. dpi: 10.1016/j.neuropharm.2011.02.024 Hinton, D. E., Pham, T., Tran, M., Safren, S. A., Otto, M. W., & Pollack, M. H. (2004). CBT for Vietnamese refugees with treatment-resistant PTSD and panic attacks: A pilot study. Journal of Traumatic Stress, 17,429-433. Hoge, C. W., Auchterlonie, J. L., & Milliken, C. S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal o f the American Medical Association, 295, 1023-1032. doi: 10.1001/ jama.295.9.1023 Hollon, S., DeRubeis, R., Shelton, R., Amsterdam, J., Salomon, R., O'Reardon, J.,...Gallop, R. (2005). Prevention of relapse following cognitive therapy vs medications in moderate to severe depression. Archives o f General Psychiatry, 62, 417-422. doi:10.1001/archpsyc.62.4.417

374

C ognitive Processing Therapy a nd PTSD

Kessler, R. C., Berglund, P., Delmer, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives o f General Psychiatry, 62, 593-602. doi: 10.1001/ archpsyc.62.6.593 Kunst, M. J. (2011). Employment status and posttraumatic stress disorder following compensation-seeking in victims of violence, journal o f Interpersonal Violence, 26, 377—393. doi:10.1177/0886260510362894 Laffaye, C., Cavella, S., Drescher, K., & Rosen, C. (2008). Relationships among PTSD symptoms, social support, and support source in veterans with chronic PTSD. Journal o f Traumatic Stress, 21, 394-401. doi: 10.1002/jts.20348 Lenz, A. S. (2013). Calculating effect size in single-case research: A comparison of nonoverlap methods. Measurement and Evaluation in Counseling and Development, 46, 64-73. doi: 10.1177/0748175612456401 Lipsey, M. W., & Wilson, D. (2001). Practical meta-analysis. Thousand Oaks, CA: Sage Publications. Makinson, R. A., & Young, J. S. (2012). Cognitive behavioral therapy and the treatment of posttraumatic stress disorder: W here counseling and neuroscience meet, journal o f Counseling and Development, 90, 131-140. doi:10.1111/j.l 556-6676.2012.00017-x Marotta, S. A. (2000). Best practices for counselors who treat posttraumatic stress disorder. Journal o f Counseling and Development, 78,492-495. doi: 10.1002/j. 15 56-6676.2000.tb0193 3.x McHugh, R. K., & Barlow, D. H. (2010). T he dissemination and implementation of evidencebased psychological treatments. American Psychologist, 65, 73-84. doi:10.1037/a0018121 Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J.,Young-Xu,Y., & Stevens, S. P. (2006). Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal o f Consulting and Clinical Psychology, 74, 898-907. doi:10.1037/0022-006X.74.5.898 National Institute for M ental Health (2005). Posttraumatic stress disorder for adults. Retrieved from http://www.nimh.nih.gov/statistics/pdf/NCS-R_data-PTSD.pdf Nepon, J., Belik, S. L., Bolton, J., & Sareen, J. (2010). The relationship between anxiety disorders and suicide attempts: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Depression and Anxiety, 27, 791-798. doi: 10.1002/da.20674 Nishith, P., Nixon, R., & Resick, P. A. (2005). Resolution of trauma-related guilt following treatment of PTSD in female rape victims: A result of cognitive processing therapy targeting comorbid depression? Journal o f Affective Disorders, 3, 259-265. doi: 10.1016/j.jad.2005.02.013 Nixon, R. D. V. (2012). Cognitive processing therapy versus supportive counseling for acute stress disorder following assault: A randomized pilot trial. Behavior Therapy, 43, 825-836. doi:10.1016/j.beth.2012.05.001 Palgi, Y., Ben-Ezra, M., Langer, S., & Essar, N. (2009). T he effect of prolonged exposure to war stress on the comorbidity of PTSD and depression among hospital personnel. Psychiatry Research, 168, 262-264. doi:10.1016/j.psychres.2008.06.003 Pinna, K., Johnson, D., & Delahanty, D. (2013). PTSD, comorbid depression, and the cortisol waking response in victims of intimate partner violence: Preliminary evidence. Anxiety, Stress, and Coping, 27, 253-69. doi: 10.1080/10615806.2013.852185 Resick, P. A., Galovski, T. A., Uhlmansiek, M. O., Scher, C. D., Clum , G. A., & Young-Xu, Y. (2008). A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. Journal o f Consulting and Clinical Psychology, 76, 243—258. doi. 10.1037/0022-006X.76.2.243 Resick, P. A., Monson, C. M., & Chard, K. M. (2007). Cognitive processing therapy: Veteran/ military version. Washington, DC: US Department of Veteran Affairs. Resick, P. A., Nishith, P., Weaver, T., Astin, M., & Feuer, C. (2002). A comparison of cognitiveprocessing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal o f Consulting and Clinical Psychology, 70, 867-879. doi:10.1037/0022-006X.70.4.867 Resick, P. A., & Schnicke, M. (1993). Cognitive processing therapy for rape victims: A treatment manual. London, England: Sage Publications. Sabri, B., Stockman, J., Bertrand, D., Campbell, D., Callwood, G., & Campbell, J. (2013). Victimization experiences, substance misuse, and mental health problems in relation to risk

375

for lethality among African American and African Caribbean women. Journal o f Interpersonal Violence, 28, 3223-3241. doi: 10.1177/0886260513496902 Schell, T. L., & Marshall, G. N. (2008). Survey of individuals previously deployed for OEF/OIF. In T. Tanielian and L. H. Jaycox (Eds.), Invisible wounds o f war: Psychological and cognitive injuries, their consequences, and services to assist recovery (pp. 87-115). Santa Monica, CA: RAND Center for Military Health Policy Research. Seligman, L., & Reichenberg, L. W. (2012). Selecting effective treatments: A comprehensive, systematic guide to treating mental disorders. San Francisco, CA: Wiley and Sons, Inc. Sledjeski, E., Speisman, B., & Dierker, L. (2008). Does number of lifetime traumas explain the relationship between PTSD and chronic medical conditions? Answers from the National Comorbidity Survey-Replication (NCS-R). Journal of Behavioral Medicine, 31, 341-349. doi: 10.1007/s 1086 5-008-9158-3 Social Security Administration (2011). Annual statistical report on the Social Security Disability Insurance Program. Washington, D C: Social Security Administration. Retrieved from http:// www.ssa.gov/policy/docs/statcornps/di_asr/201 l/di_asrl l.pdf Spinazzola, J., Blaustein, M., & van de Kolk, B. A. (2005). Posttraumatic stress disorder treatment outcome research: The study of unrepresentative samples? Journal o f Traumatic Stress 8, 425— 436. doi:10.1002/jts.20050 Ijtrauser, D., Lustig, D., Cogdal, P., & Uruk, A. (2006). Trauma symptoms: Relationship with career thoughts, vocational identity, and developmental work personality. The Career Development Quarterly, 54, 346-360. doi:10.1002/j.2161-0045.2006.tb00199.x Suris, A., Link-Malcom, J., Chard, K., Ahn, C., & North, C. (2013). A randomized clinical trial of cognitive processing therapy for veterans with PTSD related to military sexual trauma. Journal of Traumatic Stress, 26, 28-37. doi: 10.1002/jts.21765 Taylor, J. G., & Baker, S. B. (2007). Psychosocial and moral development of PTSD-diagnosed combat veterans. Journal o f Counseling and Development, 85, 364-369. doi: 10.1002/j. 15 56-6678.2007. tb00485.x Valentine, J., Pigott, T., & Rothstein, H. (2010). How many studies do you need? A primer on statistical power for meta-analysis. Journal o f Educational and Behavioral Statistics, 35, 215-247. doi: 10.3102/1076998609346961 Zappert, L., & Westrup, D. (2008). Cognitive processing therapy for posttraumatic stress disorder in a residential treatment setting. Psychotherapy Theory, Practice, and Research, 45, 361-376. doi: 10.1037/0033-3204.45.3.361

376

Copyright of Journal of Mental Health Counseling is the property of American Mental Health Counselors Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.