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Improving treatments for complex PTSD and for survivors of child abuse (first post)

I've just come across a very interesting research study published in this month's American Journal of Psychiatry:  Cloitre, M., K. C. Stovall-McClough, et al. (2010). "Treatment for PTSD Related to Childhood Abuse: A Randomized Controlled Trial." Am J Psychiatry 167(8): 915-924.  The abstract reads:  "Objective: Posttraumatic stress disorder (PTSD) related to childhood abuse is associated with features of affect regulation and interpersonal disturbances that substantially contribute to impairment. Existing treatments do not address these problems or the difficulties they may pose in the exploration of trauma memories, an efficacious and frequently recommended approach to resolving PTSD. The authors evaluated the benefits and risks of a treatment combining an initial preparatory phase of skills training in affect and interpersonal regulation (STAIR) followed by exposure by comparing it against two control conditions: Supportive Counseling followed by Exposure (Support/Exposure) and skills training followed by Supportive Counseling (STAIR/Support). Method: Participants were women with PTSD related to childhood abuse (N=104) who were randomly assigned to the STAIR/Exposure condition, Support/Exposure condition (exposure comparator), or STAIR/Support condition (skills comparator) and assessed at posttreatment, 3 months, and 6 months. Results: The STAIR/Exposure group was more likely to achieve sustained and full PTSD remission relative to the exposure comparator, while the skills comparator condition fell in the middle (27% versus 13% versus 0%). STAIR/Exposure produced greater improvements in emotion regulation than the exposure comparator and greater improvements in interpersonal problems than both conditions. The STAIR/Exposure dropout rate was lower than the rate for the exposure comparator and similar to the rate for the skills comparator. There were significantly lower session-to-session PTSD symptoms during the exposure phase in the STAIR/Exposure condition than in the Support/Exposure condition. STAIR/Exposure was associated with fewer cases of PTSD worsening relative to both of the other two conditions. Conclusions: For a PTSD population with chronic and early-life trauma, a phase-based skills-to-exposure treatment was associated with greater benefits and fewer adverse effects than treatments that excluded either skills training or exposure".

The linked free full text editorial by Richard Bryant - "The Complexity of Complex PTSD" - states "Trauma-focused therapies, and cognitive-behavioral therapy (CBT) in particular, have become the treatment of choice for posttraumatic stress disorder (PTSD) over the past two decades. A cautionary note about the general applicability of CBT has been that it may not adequately address the nature and breadth of psychological difficulties experienced by patients with more emotionally complex PTSD secondary to childhood adversity. In the article by Cloitre et al. in this issue of the Journal, this question is addressed with a controlled trial that compares the relative efficacies of standard CBT with a version of CBT that is augmented by skills training that prepares the patient for the emotional reactions associated with CBT. This trial is predicated on the premise that childhood abuse can lead to PTSD that is complicated by impairments in regulating emotion, which can compromise the ability to cope with the distress elicited by trauma-focused CBT. By training patients in emotion regulation, this therapy aims to compensate for the purported deficits in patients with more complex PTSD. The importance of this study lies in its finding that augmented CBT led to greater treatment gains and fewer dropouts from therapy in these patients than standard CBT. Although previous trials have demonstrated that CBT can effectively treat PTSD following childhood abuse or prolonged violence, this study represents the first demonstration that preparing these patients with specific training in emotion regulation skills has an additive gain over standard CBT ... One of the outstanding findings from the Cloitre et al. study was that augmented CBT resulted in less worsening of symptoms at 6-months follow-up relative to standard CBT. Considering the nature of emotion regulation problems and difficulties in managing life stressors, the finding that these patients were able to manage events after treatment in a manner that prevented deterioration suggests that the skills taught in therapy inoculated patients from subsequent stress. This important outcome provides optimism that therapy has a preventive role against stressors occurring after therapy termination.  The finding by Cloitre et al. that patients characterized by emotion regulation problems could be retained in therapy and provided with efficacious exposure-based therapy highlights the need to recognize these patients in order to provide them with a targeted intervention that is different from existing formats of CBT. Whereas there is considerable evidence that adaptations of CBT, such as dialectical behavior therapy, are efficacious in treating borderline personality disorder, these trials have not compared CBT adaptations with standard CBT. The novelty of the Cloitre et al. study is that it advances current treatments beyond their current capacity and extends this evidence-based intervention to a wider range of patients."

Very interesting and hopeful research.  Unsurprisingly I have looked for previous articles written by Marylene Cloitre.  This is no flash in the pan research.  Professor Cloitre and her team have been developing their approach to the treatment of survivors of child abuse for many years - see, for example, their 2002 paper "Skills training in affective and interpersonal regulation followed by exposure: a phase-based treatment for PTSD related to childhood abuse."  See too her books "Treating survivors of childhood abuse" and more recently "Grief in childhood: fundamentals of treatment in clinical practice".

For me, her work is both exciting and also raises a whole series of questions.  These include 1.) Would her skills-based plus trauma processing approach be relevant to others suffering from more severe forms of PTSD (e.g. some torture victims & sufferers from prolonged domestic violence) as well as for survivors of child abuse?  2.) How does this research relate to Arnoud Arntz's work treating sufferers from borderline personality disorder?  3.)  Cloitre reports an intervention that only takes 16 sessions for complex, difficult cases.  How much is her treatment very time efficient and how much has she undertreated these patients who might have done better with more prolonged work?  4.)  What is involved in her skills-training module (an adaptation of dialectical behaviour therapy) and are there lessons here for other patients?  5.)  Arntz talks about the "limited re-parenting" involved in his work.  Cloitre discusses attachment issues and the importance of the therapeutic alliance.  Are there lessons here?  6.)  Was Cloitre's trauma processing treatment component as good as it could have been e.g. comparing it with Ehlers & Clark's version of trauma-focused CBT?  I'll jot down a few thoughts about these issues in a couple of further blog posts, but for now I'm left appreciating Cloitre's good, helpful, and thought-provoking research study.


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