A Randomized Clinical Trial Comparing Affect Regulation and Social Problem-Solving Psychotherapies for Mothers With Victimization-Related PTSD

doi:10.1016/j.beth.2010.12.005

Behavior Therapy

Volume 42, Issue 4, December 2011, Pages 560-578

https://doi.org/10.1016/j.beth.2010.12.005 Get rights and content

Abstract

Addressing affect dysregulation may provide a complementary alternative or adjunctive approach to the empirically supported trauma memory processing models of cognitive behavior therapy (CBT) for posttraumatic stress disorder (PTSD). A CBT designed to enhance affect regulation without trauma memory processing—trauma affect regulation: guide for education and therapy (TARGET)—was compared to present centered therapy (PCT) and wait-list (WL) conditions in a randomized clinical trial with 146 primarily low-income and ethnoracial minority mothers with PTSD. TARGET achieved statistically and clinically significant improvement on PTSD and affect regulation measures compared to WL, with more consistent and sustained (over a 6-month follow-up period) evidence of improvement than PCT. Drop-out rates (~ 25%) were comparable in TARGET and PCT, similar to those previously reported for trauma memory processing CBTs. Symptom worsening was rare (2–8%) and transient. Affect regulation-based CBT without trauma memory processing warrants further research as a potentially efficacious therapy for victimization-related PTSD.

Highlights

► The study evaluates an affect regulation-based cognitive behavior therapy for PTSD. ► Low-income mothers with PTSD were randomly assigned to one of two therapies. ► Affect regulation therapy led to improvement in PTSD and affect regulation skills. ► Improvements were maintained at three- and six-month follow-up assessments. ► Affect regulation therapy is a potentially efficacious option for PTSD treatment.

Section snippets

Study Goals

The comparison therapy in this study was another CBT that has been shown to reduce PTSD without trauma memory processing, but that does not address affect regulation: present centered therapy (PCT; McDonagh-Coyle et al., 2005). Although PCT was not as successful as PE in achieving remission from PTSD in the McDonagh-Coyle et al., 2005, Schnurr et al., 2007 studies, PCT showed short-term evidence of benefits comparable to PE and had fewer dropouts (9 and 21% vs. 41 and 38%, respectively). PCT

Study Hypotheses

The study was designed to test the primary hypothesis that TARGET would be superior to PCT and to a WL condition in reducing PTSD symptom severity and posttraumatic beliefs. The secondary hypothesis was that TARGET would be superior to PCT and to WL in improving affect regulation and coping skills, and comparable to PCT on interpersonal functioning outcomes. The tertiary hypothesis was that TARGET would be superior to PCT and WL in reducing anxiety, depression, guilt, and parenting insecurity

Procedure

Participants were enrolled between February 4, 2005, and December 29, 2006, at health clinics, family service centers, community centers, and residential treatment centers in the Hartford, Connecticut, area, which has high rates of urban problems as assessed by arrest records, drug arrests, violent crime, firearm injuries and fatalities, family violence, and HIV rates. Applicants were screened for eligibility, assessed, and assigned to a treatment condition by one of three female interviewers

Treatment Credibility and Therapeutic Alliance

Both TARGET and PCT received uniformly high ratings for therapy credibility on the ETO, with TARGET scores higher at Sessions 1 (t = 2.41, df = 86, p = .018), 4 (t = 2.83, df = 57, p = .006), and posttest (t = 2.42, df = 60, p = .019), but equivalent at Session 10 (t = 0.76, df = 36, p = .451). Actual ETO scores ranged from 3 (a little) to 9 (extremely) for both therapies. TARGET: Session 1 (M = 7.4, SD = 1.6); Session 4 (M = 7.3, SD = 1.1); Session 10 (M = 7.9, SD = 0.9); and posttherapy (M = 7.7, SD = 1.0). PCT: Session 1 (M = 6.6, SD

Discussion

Study results show that TARGET, a relatively brief (12 weekly sessions) one-to-one CBT focused on enhancing affect regulation without trauma memory processing, was efficacious in reducing PTSD and enhancing affect regulation with a sample of predominantly low-income ethnoracial minority mothers of young children. The findings replicate evidence of efficacy for TARGET from prior studies that were done with a different population (i.e., adolescent girls with full or partial PTSD; Ford et al., in

References (73)

A.T. Beck et al.
Psychometric properties of the Beck Depression Inventory: 25 years of evaluation
Clinical Psychology Review
(1988)
S. Benish et al.
Relative efficacy of bona fide psychotherapies for treating posttraumatic stress disorder
Clinical Psychology Review
(2008)
M. Berking et al.
Emotion-regulation skills as a treatment target in psychotherapy
Behaviour Research and Therapy
(2008)
L.R. Eisner et al.
Positive affect regulation in anxiety disorders
Journal of Anxiety Disorders
(2009)
M.F. Folstein et al.
“Mini-mental state”: A practical method for grading the cognitive state of patients for the clinician
Journal of Psychiatric Research
(1975)
M. Newcomb et al.
Intergenerational cycle of maltreatment: A popular concept obscured by methodological limitations
Child Abuse and Neglect
(2001)
A.M. Nezu
A problem-solving formulation of depression
Clinical Psychology Review
(1987)
J.E. Taylor et al.
A meta-analysis of the effects of psychotherapy with adults sexually abused in childhood
Clinical Psychology Review
(2010)
M.T. Tull et al.
A preliminary investigation of the relationship between emotion regulation difficulties and posttraumatic stress symptoms
Behavior Therapy
(2007)
R. Yehuda et al.
Maternal, not paternal, PTSD is related to increased risk for PTSD in offspring of Holocaust survivors
Journal of Psychiatric Research
(2008)

C. Zlotnick et al.

Randomized controlled pilot study of cognitive–behavioral therapy in a sample of incarcerated women with substance use disorder and PTSD

Behavior Therapy

(2009)

R. Abidin

Manual for the Parenting Stress Index

(1995)

American Psychiatric Association

Diagnostic and statistical manual of mental disorders

(1994)

M. Barkham et al.

The IIP-32: A short version of the Inventory of Interpersonal Problems

British Journal of Clinical Psychology

(1996)

M. Berking et al.

Enhancing emotion-regulation skills in police officers: Results of a pilot controlled study

Behavior Therapy

(2011)

D.D. Blake et al.

The development of a Clinician-Administered PTSD Scale

Journal of Traumatic Stress

(1995)

A.S. Bryk et al.

Hierarchical linear models

(1992)

S.P. Cahill et al.

Cognitive behavior therapy for adults

C.S. Carver et al.

Assessing coping strategies: A theoretically based approach

Journal of Personality and Social Psychology

(1989)

S.J. Catanzaro et al.

Measuring generalized expectancies for negative mood regulations

Journal of Personality Assessment

(1995)

A. Charuvastra et al.

Social bonds and posttraumatic stress disorder

Annual Review of Psychology

(2008)

M. Cloitre et al.

Skills training in affective and interpersonal effectiveness in the treatment of women with PTSD

Journal of Consulting and Clinical Psychology

(2002)

M. Cloitre et al.

Attachment organization, emotion regulation, and expectations of support in a clinical sample of women with childhood abuse histories

Journal of Traumatic Stress

(2008)

M. Cloitre et al.

Treatment for PTSD related to childhood abuse: A randomized controlled trial

American Journal of Psychiatry

(2010)

J. Cohen

Statistical power for the behavioral sciences

(1988)

J.M. Cook et al.

Bridging the gap between posttraumatic stress disorder research and clinical practice

Psychotherapy: Theory, Research, Practice, Training

(2004)

C.A. Courtois et al.

Best practices in psychotherapy for adults

T. Dalgleish et al.

Reduced autobiographical memory specificity and posttraumatic stress: Exploring the contributions of impaired executive control and affect regulation

Journal of Abnormal Psychology

(2008)

R.A. Desai et al.

Impact of the seeking safety program on clinical outcomes among homeless female veterans with psychiatric disorders

Psychiatric Services

(2008)

D. Finkelhor

The trauma of child sexual abuse

Journal of Interpersonal Violence

(1987)

M.B. First et al.

Structured clinical interview for axis I and II DSM-IV disorders–Patient edition (SCID–IV/P)

(1996)

E.B. Foa et al.

Efficacy and cost-effectiveness of psychotherapy

E.B. Foa et al.

Posttraumatic Cognitions Inventory (PTCI): Development and validation

Psychological Assessment

(1999)

E.B. Foa et al.

Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: Outcome at academic and community clinics

Journal of Consulting and Clinical Psychology

(2005)

E.B. Foa et al.

Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences: Therapist guide

(2007)

J.D. Ford et al.

Treatment of complex post-traumatic self-dysregulation

Journal of Traumatic Stress

(2005)

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TARGET also resulted in greater reductions than wait-list on negative affect (p’ = 0.046) and, marginally, for cPTSD-related dysregulation (p’ = 0.065). In this RCT, findings of the outcomes of two PTSD psychotherapies obtained using a daily self-report measure were consistent with, but also extended and clarified, results from traditional outcome measures (Ford et al., 2011). The superior daily outcomes compared to wait-list of the trauma-focused emotion regulation therapy (TARGET) in reducing negative affect and cPTSD-related dysregulation and improving adaptive self-regulation adds to as yet limited evidence that trauma-focused therapies that do not require formal trauma memory processing can reduce the emotion dysregulation and enhance the functioning of adolescents (Ford, Steinberg, Hawke, Levine & Zhang, 2012) and adults (Markowitz et al., 2015) with chronic PTSD.
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^☆: This study was funded by grants from the National Institute of Justice (2004-91861-CTR-IJ; Julian Ford, principal investigator) and the Department of Justice Office of Juvenile Justice and Delinquency Programs (OJJDP-CT-52525-JS; Julian Ford, principal investigator). The authors gratefully acknowledge Drs. Debra Augenbraun, Rocio Chang, Deborah Forest, Jennifer Wolpaw, and Marisol Cruz, Jane Harrison, Kathy Medbery, Jessica Todaro, and Valerie Williams for serving as therapists, Jennifer Vendetti, Kimberly Ramaglia, and Joan Levine for serving as study interviewers, and Amy Stomsky for clerical assistance.

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A Randomized Clinical Trial Comparing Affect Regulation and Social Problem-Solving Psychotherapies for Mothers With Victimization-Related PTSD☆

Abstract

Highlights

Section snippets

Study Goals

Study Hypotheses

Procedure

Treatment Credibility and Therapeutic Alliance

Discussion

Clinical Psychology Review

Clinical Psychology Review

Behaviour Research and Therapy

Journal of Anxiety Disorders

Journal of Psychiatric Research

Child Abuse and Neglect

Clinical Psychology Review

Clinical Psychology Review

Behavior Therapy

Journal of Psychiatric Research

Behavior Therapy

Manual for the Parenting Stress Index

Diagnostic and statistical manual of mental disorders

The IIP-32: A short version of the Inventory of Interpersonal Problems

British Journal of Clinical Psychology

Enhancing emotion-regulation skills in police officers: Results of a pilot controlled study

Behavior Therapy

The development of a Clinician-Administered PTSD Scale

Journal of Traumatic Stress

Hierarchical linear models

Cognitive behavior therapy for adults

Assessing coping strategies: A theoretically based approach

Journal of Personality and Social Psychology

Measuring generalized expectancies for negative mood regulations

Journal of Personality Assessment

Social bonds and posttraumatic stress disorder

Annual Review of Psychology

Skills training in affective and interpersonal effectiveness in the treatment of women with PTSD

Journal of Consulting and Clinical Psychology

Attachment organization, emotion regulation, and expectations of support in a clinical sample of women with childhood abuse histories

Journal of Traumatic Stress

Treatment for PTSD related to childhood abuse: A randomized controlled trial

American Journal of Psychiatry

Statistical power for the behavioral sciences

Bridging the gap between posttraumatic stress disorder research and clinical practice

Psychotherapy: Theory, Research, Practice, Training

Best practices in psychotherapy for adults

Reduced autobiographical memory specificity and posttraumatic stress: Exploring the contributions of impaired executive control and affect regulation

Journal of Abnormal Psychology

Impact of the seeking safety program on clinical outcomes among homeless female veterans with psychiatric disorders

Psychiatric Services

The trauma of child sexual abuse

Journal of Interpersonal Violence

Structured clinical interview for axis I and II DSM-IV disorders–Patient edition (SCID–IV/P)

Efficacy and cost-effectiveness of psychotherapy

Posttraumatic Cognitions Inventory (PTCI): Development and validation

Psychological Assessment

Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: Outcome at academic and community clinics

Journal of Consulting and Clinical Psychology

Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences: Therapist guide

Treatment of complex post-traumatic self-dysregulation

Journal of Traumatic Stress