When do trauma experts choose exposure therapy for PTSD patients? A controlled study of therapist and patient factors

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Abstract

To investigate when and why therapists opt for or rule out imaginal exposure (IE) for patients with posttraumatic stress disorder (PTSD), 255 trauma experts were randomized to two conditions in which they were presented with four cases in which the patients' comorbidity and treatment preferences were manipulated. The results confirmed IE to be an underutilized approach, with the majority of professionals being undertrained in the technique. As predicted, the patient factors influenced the expert's choice of therapy: in case of a comorbid depression, IE was significantly less preferred than medication. Also, IE was significantly more likely to be offered when patients expressed a preference for trauma-focused treatment. The therapist factors were also found to be importantly related to treatment preferences, with high credibility in the technique being positively related to the therapists' preference for IE. Perceived barriers to IE, such as a fear of symptom exacerbation and dropout, were negatively related to the perceived suitability of the treatment when patients had suffered multiple traumas in childhood. The results are discussed in the light of clinical implications and the need of exposure training for trauma professionals.

Section snippets

Therapist factors

Training in and experience with exposure for PTSD are likely to influence the decision to use the approach. When Becker et al. (2004) asked the practising psychologists in their survey to rate these two factors, they found that only 31% had had formal training in the use of imaginal exposure (IE) and that this group was more likely to report current use of the technique than the untrained respondents. When asked to list the factors that prevented them from using IE, the respondents indicated

Patient factors

Patient variables, such as comorbidity and treatment preference may also be of importance in the therapists' choice of treatment. Becker et al. (2004) reported that a large number of clinicians (37%) saw any comorbid diagnosis as a likely contraindication for exposure (IE) for PTSD. Exploring patient preferences for exposure versus medication, Zoellner, Feeny, and Bittinger (2009) reported a similar trend: fewer therapists opted for exposure when PTSD patients had a concurrent depression.

Participants

A total of 296 trauma experts took part in our study conducted during the 2008 Annual NtVP Conference (the ‘Nederlandstalige Vereniging voor Psychotrauma’; the Dutch–Flemish Association for Psychotrauma). Forty-one participants (13.8%) did not consent to their contribution being used for research purposes. The final sample thus consisted of 255 participants: 84 men and 167 women (with four respondents not specifying their sex), with an average age of 48.83 (SD = 9.83). All participants were

Explorative survey results

Table 1 shows the means and standard deviations (SDs) for the experts' responses to the four expert variables under study per treatment type.

Discussion

In an attempt to find an explanation for the minimal use of imaginal exposure, an evidence based technique, in the treatment of posttraumatic stress disorder, we conducted an explorative survey among 255 trauma experts practising in Belgium and the Netherlands looking at level of training, treatment credibility, perceived barriers and the therapist's sex. Further, we experimentally studied the effect of patients' comorbidity and treatment preferences by randomizing the trauma experts to two

Acknowledgements

The wireless voting system used in the study reported was funded by ‘Achmea Stichting Slachtoffer en Samenleving’.

The authors are indebted to all participants for their willingness to participate in and their contribution to this study. They also like to thank the ‘Nederlandstalige Vereniging voor PsychoTrauma’ for the opportunity to conduct this research during their annual conference. They also thank José Kerstholt for her advice regarding clinical decision-making processes.

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