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BABCP spring meeting: Nick Grey on memory-focused approaches in CBT for adults with PTSD - treatment structure (2nd post)

Yesterday I wrote an introductory post on this "Memory-focused approaches ... with PTSD" workshop.  So how did it go?  It went well.  I'm definitely glad I went to this seminar.  I say "seminar" because, as is typically the case with BABCP conference-associated "workshops", there was minimal chance for participants to become practically involved.  I've been going to these BABCP conferences for many years.  Again and again, workshop formats are basically extended lectures with good opportunities for question & answer.  I find this disappointing, but I can well understand the great difficulty of making much time for practical audience involvement when "workshop" presenters are typically so pushed already to cram in all the material that they want to put into the day.  It is of course a worthwhile empirical question - is this the best way of helping participants become more effective at helping clients, or would outcomes improve more if BABCP workshops were more genuinely "workshops"?  My understanding is that the jury is still at least partially out on this one.  A major 2007 systematic review - "Effectiveness of continuing medical education" - ended with the usual "More research is needed" comment, although the authors did point out that "Live media was more effective than print.  Multimedia was more effective than single media interventions.  Multiple exposures were more effective than a single exposure." and that "Based on previous reviews, the evidence indicates that simulation methods in medical education are effective in the dissemination of psychomotor and procedural skills."  More recent work continues to underline that lecture-based teaching is very much improvable  - see, for example, the 2010 paper "Training therapists in evidence-based practice: A critical review of studies from a systems-contextual perspective" or last year's fascinating "Improved learning in a large-enrollment physics class" with its links to Anders Ericsson's work on the acquisition of expert performance through deliberate practice.

And yes "Multiple exposures are more effective than a single exposure" and, despite having been to a workshop with Nick before, I got a lot of value out of coming to today's "exposure".  So I'd like first to describe what I understand is a typical course of treatment for "simple" PTSD (following maybe one or two traumatic incidences) at the "Centre for anxiety disorders and trauma" where Nick works.  Well, the headline figure for number of treatment sessions per client is up to a dozen weekly sessions.  It's important though to qualify this figure.  Firstly it doesn't include the initial one or two assessment sessions, secondly it doesn't include the "up to three follow-up sessions" they also allow, and thirdly it's important to realise that the appointments are typically 90 minutes long (rather than the more usual 50 to 60 minutes).  So this looks like approximately 900 to 1500 minutes of therapy.  Purely in terms of total time, that's up to 30 x 50 minute sessions.  As a useful counterpoint to these comments, the day after Nick's workshop, Reg Nixon from Flinders University in Australia gave a talk at the main conference on "CBT for PTSD: Where from here?".  Reg said that although 70% of PTSD sufferers treated with trauma-focused CBT do well enough to qualify as "responders", only about 20% get to really good end state functioning with minimal PTSD symptoms.  He gave figures from a yet unpublished study by a colleague (it's under review) which assessed how much CBT was needed to get PTSD sufferers to good end state functioning (for both PTSD & depression symptoms).  About 50 to 60% apparently needed only 7 to 8 sessions (90 minute treatment sessions plus assessment plus follow-up e.g. maybe 9 to 12 sessions in total?), while 25% needed more than 12 treatment sessions (they averaged 15 to 16 plus assessment plus follow-up e.g. maybe 17 to 20 sessions total?) and 4 participants still hadn't reached good end state functioning after 18 treatment sessions.  This is helpful in clarifying both that patients with PTSD following type I trauma (rather than more complex type II) respond to varying amounts of therapy, and that trauma-focused CBT isn't a cure-all.  It seems pretty accurate to me to say that someone suffering from PTSD (following one or two major traumas) is likely to need 10 to 20 (mostly 90 minute) trauma-focused CBT sessions (assessment plus treatment plus follow-up) to get them to good end state functioning (with minimal PTSD or depression symptoms).

What about pre- and post- treatment assessment?  Nick mentioned the CAPS & SCID structured interviews for PTSD diagnosis.  He also listed several self-report measures - the IES, IES-R, PSS-R, PDS & PTCI.  What a wealth of acronyms!  If you'd like even more, see Elhai & colleagues' "Which instruments are most commonly used to assess traumatic event exposure and posttraumatic effects?: A survey of traumatic stress professionals" which asked specialists about their use of 81 different adult and 21 child/adolescent tests.  They found that "Regarding adult clinical use, the most popular measures assessing trauma history were the Posttraumatic Stress Diagnostic Scale (PDS; 16% of participants), Life Events Checklist (LEC; 10%), Detailed Assessment of Posttraumatic Stress (DAPS; 9%), and Combat Exposure Scale (CES) (9%). The most popular posttraumatic symptom assessments (used by >10%) were the Clinician-Administered PTSD Scale (CAPS), Trauma Symptom Inventory (TSI), PTSD Checklist (PCL), PDS, Keane PTSD Scale, Impact of Event Scale (IES) and revised version (IES-R), and Symptom Checklist 90-R's PTSD Subscales."  Probably most widely used here in the UK is the IAPT recommended IES-R - see this website's "Increasing access to psychological therapies (IAPT) outcomes toolkit".  The "Impact of event scale - revised (IES-R)" is a 22 item scale with a cut-off score of 33 or above.  A reduction in score of 9 or more qualifies as "statistically reliable change" - see the IAPT scoring advice.  It's likely to be worth tracking associated "disability" as well, and here the "Work & social adjustment scale (W&SAS)" is a very appropriate measure (see too the associated scoring advice).  And of course consider depression as possibly relevant as well!  See, for example, the PHQ-9 downloadable from the "Depression assessment" page of this website.  Nick also mentioned assessment of trauma-associated beliefs.  The Posttraumatic Cognitions Inventory (PTCI) is particularly relevant here.  The 1999 study introducing this questionnaire - "The posttraumatic cognitions inventory (PTCI): Development and validation" - is freely downloadable in full text from the Oxford Cognitive Therapy Centre at www.octc.co.uk/files/pdfs/PTCI.pdf and the questionnaire itself is detailed at the end of this paper.  Another trauma cognitions questionnaire it's worth considering is given in Buck, Kindt, Arntz et al's 2008 paper "Psychometric properties of the Trauma Relevant Assumptions Scale".

In tomorrow's post, I'll use this issue of appropriate assessment & monitoring to look at the way trauma-focused therapies increasingly seem to be applicable for a wider range of clients than just those suffering after single episode traumas.

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