Making raped teens relive trauma works, study says

[humble3d]

:huh:

Making raped teens relive trauma works, study says

By LINDSEY TANNER
AP Medical Writer

CHICAGO (AP) -- It almost sounds sadistic - making rape victims as young as 13 relive their harrowing assault over and over again. But a new study shows it works surprisingly well at eliminating their psychological distress.

The results are the first evidence that the same kind of "exposure" therapy that helps combat veterans haunted by flashbacks and nightmares also works for traumatized sexually abused teens with similar symptoms, the study authors and other experts said.

After exposure therapy, 83 percent no longer had a diagnosis of post-traumatic stress disorder. They fared much better than girls who got only supportive counseling - 54 percent in that group no longer had PTSD after treatment.

Girls who got exposure therapy also had much better scores on measures of depression and daily functioning than girls who got conventional counseling.

It's common to think that offering just comforting words and encouraging traumatized youngsters to forget their ordeals is protecting them, but that's "not doing them any favors," said University of Pennsylvania psychologist Edna Foa, the lead author. She said that approach can be harmful because it lets symptoms fester.

Foa developed a two-part treatment known as prolonged exposure therapy and has studied its use in treating post-traumatic stress disorder. It involves having patients repeatedly tell their awful stories, and then visit safe places that remind them of the trauma, or take part in safe activities they'd avoided because of painful reminders.

"Many are actually relieved that somebody wants to hear their story," Foa said.

The Veterans Affairs health system uses the treatment for vets with PTSD.

Foa's previous research has shown this approach works for adult rape victims, and it is used in some rape crisis centers.

Her new study was published Tuesday in the Journal of the American Medical Association.

Sixty-one girls aged 13-18 were recruited at a rape crisis center in Philadelphia. They had been raped or sexually abused, sometimes repeatedly, often by a relative. All had been diagnosed with PTSD. The researchers provided four days of prolonged exposure training for counselors at the center and two days of supportive counseling training.

The teens were randomly assigned to 14 weeks of counseling or prolonged exposure therapy from the counselors. Sessions lasted an hour or 90 minutes.

At first, most were very upset talking about what had happened. But by telling and re-telling their trauma, "they get a new perspective of what happened," Foa said. "They get used to thinking and talking about the memory and realizing that it was in the past, that it's not in the present anymore."

Eventually, "the story becomes remote and they get closure," she said.

Benefits of the prolonged exposure therapy lasted throughout a one-year follow-up.

A JAMA editorial said many therapists are reluctant to try the treatment with kids because of concerns that it might worsen symptoms, but that the study should raise awareness of the benefits.

The study "should allay therapist concerns about any potential harmful effects of exposure," said editorial author Sean Perrin, a psychologist at Lund University in Sweden and a specialist in PTSD treatment in kids. The distress that comes with reliving the trauma usually dissipates within a few sessions, and is essential to recovery, he said.

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JAMA:

http://www.jama.ama-assn.org

http://hosted.ap.org/dynamic/stories/U/US_MED_TREATING_RAPED_TEENS?SITE=AP&SECTION=HOME&TEMPLATE=DEFAULT&CTIME=2013-12-24-16-13-46#39;s not in the present anymore.

Edited December 26, 2013 by humble3d

[Turk]

Full Text: Making raped teens relive trauma works, study says (Spoiler is not working, had to remove tables and references) I am not happy with this text editor) :)

Due to personal privacy PDF link was not posted

Original Investigation

Prolonged Exposure vs Supportive Counseling Related PTSD in Adolescent Girls A Randomized Clinical Trial

Edna B. Foa, PhD; Carmen P. McLean, PhD; Sandra Capaldi, PsyD; David Rosenfield, PhD

IMPORTANCE Evidence-based treatments for posttraumatic stress disorder (PTSD) have not been established for adolescents despite high prevalence of PTSD in this population.

OBJECTIVE To examine the effects of counselor-delivered prolonged exposure therapy compared with supportive counseling for adolescents with PTSD.

DESIGN, SETTING, AND PARTICIPANTS A single-blind, randomized clinical trial of 61 adolescent girls with PTSD using a permuted block design. Counselors previously naive to prolonged exposure therapy provided the treatments in a community mental health clinic. Data collection lasted from February 2006 through March 2012.

INTERVENTIONS Participants received fourteen 60- to 90-minute sessions of prolonged exposure therapy (n = 31) or supportive counseling (n = 30).

MAIN OUTCOMES AND MEASURES All outcomes were assessed before treatment, at mid-treatment, and after treatment and at 3-, 6-, and 12-month follow-up. The primary outcome, PTSD symptom severity, was assessed by the Child PTSD Symptom Scale–Interview (range, 0-51; higher scores indicate greater severity). Secondary outcomes were presence or absence of PTSD diagnosis assessed by the DSM-IV Schedule for Affective Disorders and Schizophrenia for School-Age Children and functioning assessed by the Children’s Global Assessment Scale (range, 1-100; higher scores indicate better functioning). Additional secondary measures, PTSD severity assessed by the Child PTSD Symptom Scale–Self-Report (range, 0-51; higher scores indicate greater severity) and depression severity assessed by the Children’s Depression Inventory (range, 0-54; higher scores indicate greater severity), were also assessed weekly during treatment.

RESULTS Data were analyzed as intent to treat. During treatment, participants receiving prolonged exposure demonstrated greater improvement on the PTSD symptom severity scale (difference between treatments in improvement, 7.5; 95% CI, 2.5-12.5; P < .001) and on all secondary outcomes (loss of PTSD diagnosis: difference, 29.3%, 95% CI, 20.2%-41.2%; P = .01; self-reported PTSD severity: difference, 6.2; 95% CI, 1.2-11.2; P = .02; depression: difference, 4.9; 95% CI, 1.6-8.2; P = .008; global functioning: difference, 10.1; 95% CI, 3.4-16.8; P = .008). These treatment differences were maintained through the 12-month follow-up: for interviewer-assessed PTSD (difference, 6.0; 95% CI, 1.6-10.4; P = .02), loss of PTSD diagnosis (difference, 31.1; 95% CI, 14.7-34.8; P = .01), self-reported PTSD (difference, 9.3; 95% CI, 1.2-16.5; P = .02), depression (difference, 7.2; 95% CI, 1.4-13.0; P = .02), and global functioning (difference, 11.2; 95% CI, 4.5-17.9; P = .01).

CONCLUSION AND RELEVANCE Adolescents girls with sexual abuse–related PTSD experienced greater benefit from prolonged exposure therapy than from supportive counseling even when delivered by counselors who typically provide supportive counseling.

Author Affiliations: Department of Psychiatry, University of Pennsylvania, Philadelphia (Foa, McLean, Capaldi); Department of Psychology, Southern Methodist University, Dallas, Texas (Rosenfield).

Corresponding Author: Edna B. Foa, PhD, Department of Psychiatry, University of Pennsylvania, 3535 Market St, Sixth Floor, Philadelphia, PA 19104

Adolescence is a unique developmental stage that is as- sociated with increased exposure to traumatic events1 that can lead to posttraumatic stress disorder (PTSD).2 In turn, PTSD is associated with significant distress and func- tional impairment, increased risk for sexual revictimization,3 substance abuse,4 depression, anxiety disorders, and suicidality.5 Prolonged exposure therapy6 is the most studied evidence- based, theory-driven treatment7 for adults with PTSD,8 but it is rarely provided to adolescents because of concern that it may exacerbate PTSD symptoms9 or the belief that patients must mas- ter coping skills before exposure can safely be provided.10

To our knowledge, there are no controlled studies on treat- ments for adolescents with PTSD except for one pilot study sug- gesting prolonged exposure is beneficial for this population.11 The present study addresses this gap by comparing a pro- longed exposure program modified for adolescents (pro- longed exposure–A)12 with supportive counseling among ado- lescent girls with sexual abuse-related PTSD. Whereas most PTSD treatment studies were conducted in academic clinic set- tings, the current study was conducted in a community men- tal health clinic by counselors who received relatively mini- mal training and supervision.

We hypothesized that prolonged exposure–A would be su- perior to supportive counseling, when measured after treat- ment and at 12-month follow-up, in reducing interviewer- assessed PTSD severity, rate of PTSD diagnosis, self-reported PTSD severity and depression, and improving general func- tioning. We also hypothesized that the degree of improve- ment of PTSD and depression would be greater during pro- longed exposure–A than supportive counseling.

Methods

Participants were adolescent girls seeking treatment at a rape crisis center in Philadelphia, Women Organized Against Rape (WOAR). Inclusion criteria were female sex, age 13 to 18 years, and a primary diagnosis from the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) of chronic or subthreshold PTSD related to sexual abuse that oc- curred at least 3 months prior to assessment for the study. Sub- threshold PTSD was defined as: 1 or more re-experiencing symptoms, 2 or more avoidance symptoms, 2 or more arousal symptoms, and a total score of 14 or greater on the Child PTSD Symptom Scale–Interview.13 Exclusion criteria were current sui- cidal ideation with intent, uncontrolled bipolar disorder, schizophrenia, conduct disorder, pervasive developmental dis- order, initiation of psychotropic medication within the previ- ous 12 weeks, and current inpatient psychiatric treatment. Ado- lescents with substance use or suicidality without imminent threat were not excluded.

Procedure

The study was approved by the University of Pennsylvania in- stitutional review board and the executive board of WOAR. Sample size was determined by examining within-group ef- fect sizes from Cohen et al.14 Potential participants called WOAR’s 24-hour hotline and completed an initial screening with a WOAR counselor who assessed for sexual abuse and length of time since trauma. Adolescents who met these criteria and their nonoffending primary guardians were invited to partici- pate in a pretreatment assessment with a doctoral-level clini- cal psychologist, who served as an independent evaluator blind to treatment condition. Participants and their primary guard- ians signed informed consent/assent forms and then com- pleted a 2- to 3-hour baseline evaluation comprising a clinical interview to assess eligibility and self-report measures.

After the baseline evaluation, participants completed 1 to 3 preparatory sessions to address case management issues such as safety concerns, legal issues, parental involvement, and in- terest in receiving treatment. If safety issues (eg, active sui- cidal plans) were identified during the preparatory sessions, participants were excluded from the study and referred else- where. Participants who completed the preparatory phase were randomized to receive prolonged exposure–A or supportive counseling using a parallel design and a permuted block pro- cedure with 10 randomizations per block (1:1 ratio), gener- ated prior to beginning enrollment. On completing the prepa- ratory phase but prior to the patient beginning treatment, a research assistant consulted the randomization table and no- tified the therapist of the patient’s treatment condition.

Assessment

Participants’ demographic characteristics were collected at the baseline evaluation. Participants were asked to self-identify as black, white, Hispanic, biracial, other, or no response. Race/ ethnicity data were collected for future moderator analyses. Participants completed self-report measures of PTSD and depression prior to each treatment session and at all blinded independent evaluations, which occurred before treatment, at mid-treatment, and after treatment and at 3-, 6-, and 12-month follow-up.

Primary Outcome

The Child PTSD Symptom Scale–Interview (CPSS-I)13,15 as- sesses PTSD diagnosis and symptom severity for ages 8 to 18 years. Scores range from 0-51 (0-10, below threshold; 11-15, sub- clinical; 16-20, mild; 21-25, moderate; 26-30, moderately se- vere; 31-40, severe; 41-51, extremely severe). It has excellent internal consistency (Cronbach α = .83-.89)13,15 and test- retest reliability (.84-.86).13,15 Convergent validity and dis- criminant validity are high.13,15

Secondary Outcomes

The DSM-IV Schedule for Affective Disorders and Schizophre- nia for School-Age Children (K-SADS)16 is a semistructured in- terview assessing current and lifetime psychiatric disorders. It has excellent psychometric properties.16 The K-SADS PTSD module was administered at all independent evaluator assess- ments to determine presence/absence of PTSD diagnosis.

Treatments

Treatment was delivered by 4 master’s-level counselors at WOAR who received group supervision every other week from 2 of the authors (E.B.F. and S.C.). Counselors attended a 4-day prolonged exposure training workshop (E.B.F.) and two 2-day supportive counseling trainings conducted by Judith Cohen, MD, and Esther Deblinger, PhD.14

The prolonged exposure–A program12 consists of up to 14 weekly 60- to 90-minute sessions. Treatment comprises 8 mod- ules, each focusing on illustrating a particular component in the session. Homework exercises provide the opportunity for repeating the material outside of session. The program for- mat allows flexibility for the counselor to present a module in 1 or more sessions depending on the adolescent’s develop- mental level, attention span, and specific needs.

Module 1 presents the treatment rationale. Module 2 in- cludes information gathering, identifying an index trauma, and conducting a breathing retraining exercise. Module 3 pre- sents common reactions to trauma. Module 4 includes discus- sion of the rationale for in vivo exposure (confronting trauma reminders in real life), creation of the in vivo hierarchy, and assignment of in vivo homework. Module 5 includes presen- tation of the rationale for imaginal exposure (revisiting and re- counting the traumatic memory), conducting imaginal expo- sure for 15 to 45 minutes, and processing this revisiting experience. This module is repeated for 2 to 5 sessions. In mod- ule 6, the imaginal exposure focuses on the worst moments of the trauma. Module 6 is repeated for 4 to 7 sessions. Mod- ule 7 focuses on generalization of skills learned in treatment and on relapse prevention. Module 8 comprises a “final proj- ect,” such as making booklets detailing the trauma and the gains made in treatment.

Supportive counseling consisted of up to 14 weekly 60-to 90-minute sessions of client-centered therapy21 for trauma- tized children. Client-centered therapy is based on the Trauma- genic Dynamics Model22 of symptom formation after child

sexual abuse and the Rogerian psychotherapy model.23 Sup- portive counseling sessions focus on establishing a trusting, empowering, and validating therapeutic relationship. Partici- pants are allowed to choose when, how, and whether or not to address their trauma. In session 1, participants are ori- ented to supportive counseling. Counselors provide active lis- tening, empathy, and encouragement to talk about feelings and express belief in the participant’s ability to cope. In sessions 4 and 8, participants are asked how they feel about their trauma. With this exception, participants direct the sessions. Counselors note discussion of the trauma and the time de- voted to such discussions. No participants in the supportive counseling condition described their trauma during the ses- sions.

Treatment Adherence

Counselors’ adherence to treatment protocols was moni- tored via review of session videos during supervision meet- ings. Additionally, 20% of treatment sessions were randomly selected and rated by trained adherence raters who were oth- erwise uninvolved in the study. Raters assessed adherence to essential components of each treatment and monitored pro- tocol violations.

Figure. Consort Diagram of Participant Flow Through the Protocol

327 Individuals screened for presence of sexual abuse and >3 mo since trauma

212 Excluded

86 Did not meet inclusion criteria

37 Declined to participate

27 Met exclusion criteria

21 Could not get parental consent because of custody issues

16 Had <3 mo since trauma

11 Refused any treatment

8 Wanted group treatment only

6 Had late-stage pregnancy

115 Scheduled for baseline evaluation

25 Excluded

13 Did not meet inclusion criteria

12 Met exclusion criteria

90 Consented and entered into preparation phase

29 Excluded (not randomized)

11 Removed from study by principal investigator for safety reasons

13 Stopped attending preparatory sessions

5 Did not attend any preparatory sessions after consenting to study

61 Randomized

Discussion

The results of this study indicate that after treatment, par- ticipants who received prolonged exposure–A showed greater improvement in PTSD symptoms and were more likely to lose their PTSD diagnosis and be classified as good responders (CPSS-I score ≤ than those who received sup- portive counseling. Symptoms of PTSD for prolonged exposure–A participants were in the nonclinical range after treatment and at follow-up (below 10), whereas symptoms were in the low end of the clinical range (above 15) for sup- portive counseling participants. Moreover, participants who received prolonged exposure–A demonstrated greater improvement in depressive symptoms and functioning than those who received supportive counseling. The superiority of prolonged exposure–A over supportive counseling was also evident at 12-month follow-up. These results are consis- tent with those of Gilboa-Schechtman et al11 and the adult PTSD treatment literature in which prolonged exposure has been found superior to supportive counseling treatments for both PTSD symptoms and associated problems.28 It is inter-esting to note that improvements made during treatment were maintained throughout the follow-up period, regard- less of the type of treatment received.

There are 2 important aspects of the study. First, we ad- opted a rigorous randomized clinical trial design that affords clear conclusions from the results. Second, treatments were delivered by counselors at a community mental health clinic to treatment-seeking adolescents at that clinic. These coun- selors had no prior experience with manualized therapy or evi- dence-based approaches, including prolonged exposure–A. It is particularly compelling that prolonged exposure–A was su- perior to supportive counseling in the hands of counselors who were more accustomed to delivering counseling than pro- longed exposure–A.

Several caveats should be noted. First, the prerandomiza- tion preparatory sessions may reduce generalizability to treat- ment studies in which participants are randomized immedi- ately after the baseline evaluation. On the other hand, the preparatory sessions parallel routine clinical practice in which therapists typically spend some sessions preparing the pa- tient before initiating an intervention. Notably, the average number of preparatory sessions was minimal: 1.48 for pro- longed exposure–A and 1.53 for supportive counseling. Sec- ond, the preparatory sessions occurred prior to randomiza- tion, which may have biased the sample by excluding inappropriate participants and including more motivated ones. However, the preparatory sessions ensured participant safety by providing the flexibility to discuss important issues (eg, per- sonal safety, information sharing with parents) germane to the developmental stage of adolescence. Notably, there were no differences between randomized and nonrandomized samples on any pretreatment variables. Third, because the sample com- prised female adolescents whose PTSD was related to sexual abuse, the results may not generalize to PTSD related to other types of traumas or to males. However, prolonged exposure for adolescents includes all the active components of pro- longed exposure for adults, which has been found to be effec- tive among men and women with PTSD related to a wide range of traumas. The close similarity between the 2 protocols strongly suggests that our results are generalizable to PTSD in adolescence in general. In addition, the study by Gilboa- Schechtman et al11 found that prolonged exposure–A was ef- fective for adolescent boys and girls with mixed traumas.

An important clinical implication of these results is the fea- sibility of disseminating and implementing prolonged expo- sure–A in community mental health clinics for adolescents who are motivated to participate in treatment. Prolonged expo- sure–A was successfully implemented by counselors with no prior training in evidence-based treatments and with rela- tively little supervision from experts. This is important be- cause the need for evidence-based treatment of PTSD far ex- ceeds the availability of these services. To address this disparity, the Veteran Affairs (VA) system and Department of Defense (DoD) have recommended prolonged exposure as a first-line treatment for PTSD and have promoted widespread dissemi- nation of prolonged exposure.29-31 Like the VA and DoD, com- munity mental health clinics, and especially rape crisis clin- ics, which routinely treat traumatized patients, are a logical target for disseminating prolonged exposure.

Conclusions

Adolescents with sexual abuse–related PTSD experienced greater benefit from prolonged exposure therapy than from supportive counseling even when treatment was delivered by counselors at a community mental health clinic who typi- cally provide supportive counseling.

Edited December 26, 2013 by Turk