Research roundup: Adapting evidence-based treatments for adults with PTSD

APA is currently updating its 2017 Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults, which is based on systematic reviews of the scientific evidence, an assessment of the benefits, harms/burdens, balance of benefits to harms/burdens, patient values and preferences, and applicability. The updated guideline will include treatment recommendations and two new sections: one section addresses ways to implement the recommended treatments with the patient who is in the office in this moment, and another will include recommendations for future research. Both the draft updated clinical practice guideline and a new professional practice guideline on working with adults who experienced trauma will be out for public review and comment soon.

In this installment of “Research Roundup,” we explore the latest research on ways to adapt the delivery, format, and content of guideline recommended interventions to meet the diverse needs of individuals suffering from PTSD or substance use disorder. The first study examines whether there is a difference in veterans’ PTSD outcomes in those who receive the interventions via in-person in the home or telehealth. The second study looks at a novel mHealth intervention to prevent developing PTSD and alcohol misuse in women who recently experienced a sexual assault. The final study provides an example of culturally adapting an evidence-based intervention for Native Americans with substance use disorder.

Note: In addition to reviewing the research summaries, psychologists are encouraged to further explore the literature to determine what may be useful to them in practice, particularly as it relates to patients’ values, culture, and preferences.

McGeary, C. A., Morland, L. A., Resick, P. A., Straud, C. L., Moring, J. C., Sohn, M. J., Mackintosh, M.-A., Young-McCaughan, S., Acierno, R., Rauch, S. A. M., Mintz, J., McGeary, D. D., Wells, S. Y., Grubbs, K., Nabity, P. S., McMahon, C. J., Litz, B. T., Velligan, D. I., Macdonald, A.,…Peterson, A. L. (2023). Impact and efficiency of treatment across two PTSD clinical trials comparing in-person and telehealth service delivery formats. Psychological Services. Advance online publication. https://dx.doi.org/10.1037/ser0000774opens in new window

The average recommended number of sessions for the strongly recommended treatments for PTSD (APA, 2017), cognitive processing therapy (CPT) and prolonged exposure (PE), range between 12–15 weekly sessions, and notable changes may occur around session 8. However, some patients may dropout early from these effective treatments due to a variety of logistical issues, ranging from needing transportation to having to take time off work. Recent research has demonstrated increased treatment engagement and improved PTSD outcomes when patients received PE or CPT in their own home (traditionally known as “house calls;” Morland et al., 2020; Peterson et al., 2022). Given that there is little research comparing the efficacy and acceptability of PE or CPT delivered in the patients’ home via in-person or telehealth versus in the office, the study authors wanted to examine whether patients who received PE or CPT in the home via in-person or telehealth had greater treatment engagement than those who received these treatments in-person in the office or via telehealth at a satellite clinic.

Data of 268 patients with PTSD from two multisite clinical trials were combined. Patients in the first trial received 12 sessions of CPT for over six weeks and, prior to the start of the study, they were offered the opportunity to choose whether to have CPT delivered in-person in the home or office or via telehealth in the home or at a satellite clinic (Peterson et al., 2022). In the second trial patients were randomized to receive 6–15 individual 90-minute sessions of PE in one of three delivery formats: in-person at home, telehealth at home, or in the office (Morland et al., 2020). With this combined data set, the study authors predicted that patients who received PE or CPT in their home environment (either with a “house call” therapist or via telehealth) would be more engaged in the treatment (i.e., complete at least eight or more sessions) and improve quicker than those who received treatment in person in the office or via telehealth at a satellite clinic.

Patients who received CPT or PE with a “house call” therapist reported being the most engaged in treatment with an average attendance of 10 sessions as well as significant reductions in PTSD symptoms. The in-home telehealth group also reported attending on average a similar number of sessions as the in-home in-person group, though reliable changes in PTSD symptoms did not occur in this group. Patients who were receiving treatment in-person in the office or via telehealth at a satellite clinic reported being the least engaged in treatment, attending on average seven sessions. While there were no significant differences across treatment delivery formats in the number of days needed to reach session 8, house call therapists had direct access to the patients’ home environment which allowed them to efficiently tailor treatments. Patients in the house call group were likely able to apply the necessary skills more quickly than if they were to receive treatment via telehealth or in the office. More research, though, is needed on the efficacy of providing therapy in the home in-person with other populations, as the patients included in these studies were primarily veterans.

Dworkin, E. R., Schallert, M., Lee, C. M., & Kaysen, D. (2023). Pilot randomized clinical trial of an app-based early intervention to reduce PTSD and alcohol use following sexual assault. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. https://doi.org/10.1037/tra0001460opens in new window

According to a meta-analysis of follow-up studies of women who experienced sexual assault within the last 12 months, over 75% of women met criteria for PTSD (Dworkin et al., 2021), and this vulnerable population is also at risk of using alcohol to cope with PTSD symptoms. Access to evidence-based treatment after the assault is critical to reduce the likelihood of developing PTSD and misusing alcohol, though when the assault happens the individual may not have the time or resources to seek help or may be afraid to disclose the traumatic event. To reduce the likelihood of developing PTSD and alcohol misuse, the study authors created a mobile app based on CBT principles (i.e., activity scheduling, cognitive restructuring) for survivors to use within the first 10 weeks after the sexual assault.

In this pilot study, 41 racially, ethnically, and sexually diverse women were randomized to receive either the Tools for Health and Resilience after Interpersonal Violence Exposure (THRIVE) mobile app intervention or an alternative app intervention. THRIVE is a 21-day mobile app intervention that includes modules that are based on CBT principles such as behavioral activation (i.e., activity scheduling) and cognitive restructuring (i.e., identifying and modifying maladaptive thoughts) and self-monitoring of PTSD symptoms and alcohol use. There is also an optional module on improving relationships with family and friends, such as how to share a traumatic event with a loved one. Participants also received four weekly 10–20-minute coaching calls that emphasized applying the CBT skills within the modules to their everyday setting. Participants in the control group used an alternative app that allowed them to record their symptoms and alcohol use as well as receive supportive telephone coaching, but without the CBT principles. Participants completed self-rating forms on their PTSD symptoms, problems with alcohol, and alcohol use at baseline and were followed up 3 weeks and 3 months postintervention.

Participants in the THRIVE intervention group showed significant reductions in PTSD symptoms, problematic alcohol use, and amount of alcohol consumed within the week. These significant improvements remained at 3-month follow-up and, most notably, participants in the intervention group were less likely to report drinking to cope with their traumatic event. While further research is needed on the efficacy of the THRIVE app, which is still under development, as well as any potential harms and burdens the app could impose, this study exemplifies how evidence-based early interventions can be adapted via mHealth.

Walker, D., Pearson, C., Day, A., Bedard-Gilligan, M., Saluskin, K., Huh, D., & Kaysen, D. (2023). A community engaged approach to adapting motivational interviewing and skills training for Native Americans with experiences of substance misuse. American Journal of Health Promotion, 37(6), 796–806. https://doi.org/10.1177/08901171231161467opens in new window

Results from the 2018 National Survey on Drug Use and Health report the Native American population misusing alcohol and substances more than any other ethnic group. Historical trauma experienced by Native Americans may contribute to higher use of unhealthy coping mechanisms such as alcohol and substances. Interventions such as Motivational Interviewing with Skills Training (MIST) can help individuals reduce substance use and address trauma, though the intervention was developed and studied in a mostly White population. The study authors were motivated to adapt the evidence-based intervention to meet the culture and social needs of the Yakima Nation tribe in the Pacific Northwest and explore the feasibility and acceptability of adapting this intervention.

Prior to providing the intervention, the study authors established a partnership with the community leaders and Elders of the Yakima Nation to review together the MIST protocol to determine if any changes were warranted for it to be feasible and acceptable for members of the tribe. Interestingly, community leaders recommended reducing the amount of homework for individuals to complete after sessions and instead provide encouragement to practice and apply the skills outside of session. Language within the MIST protocol was revised to have a more honest, respectful, peaceful tone to reflect how the members of the tribe communicate with each other as well as to be in line with the tribe’s sacred virtues. The study authors also took care to ensure that imagery within the protocol and handouts were representative of the cultural traditions, such as the medicine wheel that symbolizes the interaction of all individuals, animals, and Earth.

Fifty participants who reported having used substances as a coping mechanism received the culturally-adapted MIST intervention, and many participants responded positively to the intervention. Participants found that the adapted intervention made them feel understood, and they found the healthy ways of coping helpful and useful. Some participants even noted a cascading effect of improvement in not only reducing their substance use but also reducing PTSD symptom severity. Some also thought that six 90–120-minute sessions were not enough. Feedback from the nine counselors who provided treatment mirrored the participants, and they appreciated the collaborative relationship involved in working through the participants’ traumas. Overall, by developing partnerships with local communities and reviewing the protocol closely to ensure the language and format match appropriately with the culture, vulnerable populations can receive the necessary evidence-based care they need to reduce suffering.

Altogether, these studies further contribute to how the evidence-based treatments’ content, delivery, and format can be adapted to meet the patients’ values, culture, and preferences. The studies exemplify the application of evidence-based practice in psychology by not only referring to the latest research on the particular modality but by also applying the clinician expertise and patients’ values, preferences, and culture throughout treatment. There continues to be a clear need for more research on adapting existing evidence-based treatments for PTSD and substance misuse, such as CPT, PE, and motivational interviewing, to fit the needs of particular populations and settings. In the meantime, psychologists will need to continue to provide the best care possible. Utilizing the framework of evidence-based practice in psychology is a useful structure for identifying the best available research to make decisions and recommendations about options for care, while tailoring those options based on patients’ own values and culture through the expertise of the clinician and guidance of research.