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Adapting Trauma-Focused Psychotherapies to Expand the Reach of PTSD Care

Carmen P. McLean, Nadia Malek, & Casey Straud

May 28, 2024

 

Challenges to Assumptions about TFT

Mental health treatment for posttraumatic stress disorder (PTSD) in general, and trauma-focused treatment (TFT) in particular, is traditionally delivered by trained expert mental health clinicians, such as clinical psychologists and licensed clinical social workers. TFT, on account of being more challenging to clients than non-trauma-focused treatment (to say nothing of the misconceptions about its safety and tolerability), has been especially restricted to the purview of expert clinicians. However, research over the past decade has begun to challenge some of our assumptions about how clients can effectively participate in TFT.

One assumption is that TFT must be delivered by a provider (i.e., face-to-face or telehealth). However, trauma-focused internet-based interventions (IBIs) have been found efficacious in reducing PTSD severity in several independent research groups (see Lewis et al., 2019). Many trauma-focused IBIs involve self-guided exposure exercises, where individuals engage independently, for example, in written imaginal exposure or the planning and implementation of in vivo exposure. Adapting TFT for online delivery has the potential to increase the reach of PTSD care relative to traditional care options because web programs can typically be accessed at any time or place and with greater anonymity. Much less research has challenged the assumption that TFT must be provided or facilitated by an expert clinician. There are studies showing that task shifting or task sharing the role of the mental health therapist to a less expert professional is generally an effective approach for delivering skills-based, time-limited mental health interventions (see Cohen & Yaeger, 2021), but limited work in this vein has targeted TFTs. Exceptions to this are studies on task shifting the delivery of cognitive processing therapy (e.g., Bass et al., 2013) and prolonged exposure therapy (Rossouw et al., 2018), which has yielded promising results.

New Study on TFT Delivery 

 

Our recent study (McLean et al., 2024) represents an attempt to simultaneously challenge assumptions about how TFT can be delivered and who can support trauma-focused IBIs. We adapted written exposure therapy (WET; Sloan & Marx, 2019) for delivery in an online program. Veterans with clinically significant PTSD symptoms were offered 4-8 sessions of the online program and completed assessments before, during, and after treatment. Rather than having a clinician provide participants with instruction and feedback on their imaginal exposure narrative, we trained peer coaches with previous experience facilitating online cognitive behavioral therapy programs to support participants via an online chat. The clinical outcomes were very promising: we found that participants experienced clinically meaningful reductions in PTSD symptoms and depressive symptoms and showed improvement in functioning. We also found that half the participants who were offered the program never started and even among those that started, many participants only completed some of the sessions, and did not complete the full program. While our findings suggest that online delivery of WET facilitated by peer coaches was feasible and could be very effective for some individuals, the acceptability of this modality requires further research.

Future Avenues of Research

 

Our findings raise interesting questions about who is best suited for IBIs. There were many veterans who expressed interest in participating, and then did not engage in treatment. It would be helpful to better under who is most likely to engage in and complete a trauma-focused IBI so that recruitment efforts could be targeted to those persons. We currently know very little about who prefers which modalities of care or which level of human support. Another interesting set of questions surrounds which TFT are best suited for online delivery and/or for task shifting. It is our contention that WET is particularly well suited to both forms of adaptation, given its streamlined focus on one TFT component (imaginal exposure), the independent nature of the writing exercise, and the inclusions of scripted instructions. However, it’s possible that adaptations to more complex TFTs also prove feasible, especially in light of rapid advancements in technology (e.g., artificial intelligence).

 

We hope to see research on novel adaptations of TFT continue. The importance of this work is underscored by the fact that standard expert-delivered PTSD treatment does not, and will not ever, verge on meeting the global need for effective PTSD care. Not only are there far too few expert mental health professionals relative to prospective clients, but there are also logistic and stigma-related barriers to accessing expert-delivered mental health treatment. Adapting TFT in ways that can make effective interventions more cost effective and scalable has the potential to expand the reach of evidence-based PTSD care. Future work should endeavor to evaluate outcomes and acceptability of novel adaptations that continue to test our assumptions about the delivery of TFT.

Discussion Questions 

1. What are the potential benefits (and possible pitfalls) that should be considered in the development of IBI’s for PTSD?

2. What unique patient and provider barriers might be important to consider for online adapted TFT for PTSD?

3. Based on study results, what novel adaptation should be tested in the future for the delivery of TFT for PTSD?

About the Authors 

 

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Carmen P. McLean, PhD, is a licensed Clinical Psychologist at the National Center for PTSD’s Dissemination and Training Division at the Palo Alto VA and a Clinical Professor (Affiliate) at the Department of Psychiatry and Behavioral Sciences at Stanford University. Her research examines ways to increase the reach of exposure therapy for PTSD by addressing implementation barriers and testing digital exposure-based interventions with the goal of helping more individuals with PTSD benefit from effective treatment. Dr. McLean can be followed @CarmenMcLeanPhD.

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Nadia Malek, BA, received her bachelor’s degree in Psychological Science from the University of California, Irvine in 2021. She is currently a research assistant at the National Center for PTSD’s Dissemination and Training Division at the Palo Alto VA and an incoming graduate student at the Arizona State University Clinical Psychology doctoral program. Nadia can be followed @NadiaMalek22.

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Casey L. Straud, PsyD, ABPP, is a board certified and licensed clinical psychologist, and Assistant Professor in the Department of Psychiatry and Behavioral Sciences at the University of Texas Health Science Center at San Antonio. His research focuses on biopsychosocial mechanisms that can be combined with first-line, trauma focused psychotherapies to improve PTSD treatment outcomes. Dr. Straud can be followed @Casey_Straud.

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Sloan, D. M. & Marx, B. P. (2019). Written Exposure Therapy for PTSD: A Brief Treatment Approach for Mental

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