Showing papers in "Journal of Consulting and Clinical Psychology in 2010"

The Effect of Mindfulness-Based Therapy on Anxiety and Depression: A Meta-Analytic Review

Abstract: Objective:Although mindfulness-based therapy has become a popular treatment, little is known about its efficacy. Therefore, our objective was to conduct an effect size analysis of this popular intervention for anxiety and mood symptoms in clinical samples.Method:We conducted a literature search using PubMed, PsycINFO, the Cochrane Library, and manual searches. Our meta-analysis was based on 39 studies totaling 1,140 participants receiving mindfulness-based therapy for a range of conditions, including cancer, generalized anxiety disorder, depression, and other psychiatric or medical conditions. Results:Effect size estimates suggest that mindfulness-based therapy was moderately effective for improving anxiety (Hedges’sg!0.63) and mood symptoms (Hedges’sg!0.59) from pre- to posttreatment in the overall sample. In patients with anxiety and mood disorders, this intervention was associated with effect sizes (Hedges’sg) of 0.97 and 0.95 for improving anxiety and mood symptoms, respectively. These effect sizes were robust, were unrelated to publication year or number of treatment sessions, and were maintained over follow-up.Conclusions:These results suggest that mindfulnessbased therapy is a promising intervention for treating anxiety and mood problems in clinical populations.

Therapist Adherence/Competence and Treatment Outcome: A Meta-Analytic Review

Abstract: Objective: The authors conducted a meta-analytic review of adherence–outcome and competence– outcome findings, and examined plausible moderators of these relations. Method: A computerized search of the PsycINFO database was conducted. In addition, the reference sections of all obtained studies were examined for any additional relevant articles or review chapters. The literature search identified 36 studies that met the inclusion criteria. Results: R-type effect size estimates were derived from 32 adherence–outcome and 17 competence–outcome findings. Neither the mean weighted adherence– outcome (r .02) nor competence–outcome (r .07) effect size estimates were found to be significantly different from zero. Significant heterogeneity was observed across both the adherence–outcome and competence–outcome effect size estimates, suggesting that the individual studies were not all drawn from the same population. Moderator analyses revealed that larger competence–outcome effect size estimates were associated with studies that either targeted depression or did not control for the influence of the therapeutic alliance. Conclusions: One explanation for these results is that, among the treatment modalities represented in this review, therapist adherence and competence play little role in determining symptom change. However, given the significant heterogeneity observed across findings, mean effect sizes must be interpreted with caution. Factors that may account for the nonsignificant adherence– outcome and competence–outcome findings reported within many of the studies reviewed are addressed. Finally, the implication of these results and directions for future process research are discussed.

Enhancing Treatment Outcome of Patients at Risk of Treatment Failure: Meta-Analytic and Mega-Analytic Review of a Psychotherapy Quality Assurance System.

Abstract: Objective: Outcome research has documented worsening among a minority of the patient population (5% to 10%). In this study, we conducted a meta-analytic and mega-analytic review of a psychotherapy quality assurance system intended to enhance outcomes in patients at risk of treatment failure. Method: Original data from six major studies conducted at a large university counseling center and a hospital outpatient setting (N 6,151, mean age 23.3 years, female 63.2%, Caucasian 85%) were reanalyzed to examine the effects of progress feedback on patient outcome. In this quality assurance system, the Outcome Questionnaire–45 was routinely administered to patients to monitor their therapeutic progress and was utilized as part of an early alert system to identify patients at risk of treatment failure. Patient progress feedback based on this alert system was provided to clinicians so that they could intervene before treatment failure occurred. Meta-analytic and mega-analytic approaches were applied in intent-to-treat and efficacy analyses of the effects of feedback interventions. Results: Three forms of feedback interventions—integral elements of this quality assurance system—were effective in enhancing treatment outcome, especially for signal alarm patients. Two of the three feedback interventions were also effective in preventing treatment failure (clinical support tools and the provision of patient progress feedback to therapists). Conclusions: The current state of evidence appears to support the efficacy and effectiveness of feedback interventions in enhancing treatment outcome.

Depression, craving, and substance use following a randomized trial of mindfulness-based relapse prevention.

Abstract: Addiction has generally been characterized as a chronic and relapsing condition (Connors, Maisto, & Zywiak, 1996; Leshner, 1999). Research on the relapse process has implicated numerous risk factors that appear to be the most robust and immediate predictors of posttreatment substance use, including negative affect, craving or urges, interpersonal stress, motivation, self-efficacy, and ineffective coping skills in high-risk situations (Connors et al.,1996; Witkiewitz & Marlatt, 2004). Targeting these risk factors during treatment, either pharmacologically (e.g., naltrexone to reduce alcohol craving; Richardson et al., 2008) or behaviorally (e.g., coping skills training; Monti et al., 2001), has become a priority for substance abuse researchers and clinicians.

Dialectical behavior therapy for borderline personality disorder: a meta-analysis using mixed-effects modeling.

Abstract: Objective:At present, the most frequently investigated psychosocial intervention for borderline personality disorder (BPD) is dialectical behavior therapy (DBT). We conducted a meta-analysis to examine the efficacy and long-term effectiveness of DBT.Method:Systematic bibliographic research was undertaken to find relevant literature from online databases (PubMed, PsycINFO, PsychSpider, Medline). We excluded studies in which patients with diagnoses other than BPD were treated, the treatment did not comprise all components specified in the DBT manual or in the suggestions for inpatient DBT programs, patients failed to be diagnosed according to theDiagnostic and Statistical Manual of Mental Disorders, and the intervention group comprised fewer than 10 patients. Using a mixed-effect hierarchical modeling approach, we calculated global effect sizes and effect sizes for suicidal and self-injurious behaviors. Results:Calculations of postintervention global effect sizes were based on 16 studies. Of these, 8 were randomized controlled trials (RCTs), and 8 were neither randomized nor controlled (nRCT). The dropout rate was 27.3% pre- to posttreatment. A moderate global effect and a moderate effect size for suicidal and self-injurious behaviors were found, when including a moderator for RCTs with borderline-specific treatments. There was no evidence for the influence of other moderators (e.g., quality of studies, setting, duration of intervention). A small impairment was shown from posttreatment to follow-up, including 5 RCTs only.Conclusions:Future research should compare DBT with other active borderline-specific treatments that have also demonstrated their efficacy using several long-term follow-up assessment points.

Disasters and Youth: A Meta-Analytic Examination of Posttraumatic Stress

Abstract: Objective: Meta-analyze the literature on posttraumatic stress (PTS) symptoms in youths post-disaster. Method: Meta-analytic synthesis of the literature (k = 96 studies; Ntotal = 74,154) summarizing the magnitude of associations between disasters and youth PTS, and key factors associated with variations in the magnitude of these associations. We included peer-reviewed studies published prior to 1/1/2009 that quantitatively examined youth PTS (≤18 years at event) after a distinct and identifiable disaster. Results: Despite variability across studies, disasters had a significant effect on youth PTS (small-to-medium magnitude; rpooled = .19, SEr = .03; d = 0.4). Female gender (rpooled = .14), higher death toll (disasters of death toll ≤25: rpooled = .09; vs. disasters with ≥1,000 deaths: rpooled = .22), child proximity (rpooled = .33), personal loss (rpooled = .16), perceived threat (rpooled = .34), and distress (rpooled = .38) at time of event were each associated with increased PTS. Studies conducted within 1 year post-disaster, studies that used established measures, and studies that relied on child-report data identified a significant effect. Conclusion: Youths are vulnerable to appreciable PTS after disaster, with pre-existing child characteristics, aspects of the disaster experience, and study methodology each associated with variations in the effect magnitude. Findings underscore the importance of measurement considerations in post-disaster research. Areas in need of research include the long-term impact of disasters, disaster-related media exposure, prior trauma and psychopathology, social support, ethnicity/race, prejudice, parental psychopathology, and the effects of disasters in developing regions of the world. Policy and clinical implications are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved). Language: en

A randomized clinical trial of acceptance and commitment therapy versus progressive relaxation training for obsessive-compulsive disorder.

Abstract: Objective: Effective treatments for obsessive-compulsive disorder (OCD) exist, but additional treatment options are needed. The effectiveness of 8 sessions of acceptance and commitment therapy (ACT) for adult OCD was compared with progressive relaxation training (PRT). Method: Seventy-nine adults (61% female) diagnosed with OCD (mean age 37 years; 89% Caucasian) participated in a randomized clinical trial of 8 sessions of ACT or PRT with no in-session exposure. The following assessments were completed at pretreatment, posttreatment, and 3-month follow-up by an assessor who was unaware of treatment conditions: Yale–Brown Obsessive Compulsive Scale (Y-BOCS), Beck Depression Inventory–II, Quality of Life Scale, Acceptance and Action Questionnaire, Thought Action Fusion Scale, and Thought Control Questionnaire. Treatment Evaluation Inventory was completed at posttreatment. Results: ACT produced greater changes at posttreatment and follow-up over PRT on OCD severity (Y-BOCS: ACT pretreatment 24.22, posttreatment 12.76, follow-up 11.79; PRT pretreatment 25.4, posttreatment 18.67, follow-up 16.23) and produced greater change on depression among those reporting at least mild depression before treatment. Clinically significant change in OCD severity occurred more in the ACT condition than PRT (clinical response rates: ACT posttreatment 46%–56%, follow-up 46%–66%; PRT posttreatment 13%–18%, follow-up 16%–18%). Quality of life improved in both conditions but was marginally in favor of ACT at posttreatment. Treatment refusal (2.4% ACT, 7.8% PRT) and dropout (9.8% ACT, 13.2% PRT) were low in both conditions. Conclusions: ACT is worth exploring as a treatment for OCD.

Posttraumatic stress symptoms among National Guard soldiers deployed to Iraq: associations with parenting behaviors and couple adjustment.

Abstract: Objective: In this article, we report findings from a 1-year longitudinal study examining the impact of change in posttraumatic stress disorder (PTSD) symptoms following combat deployment on National Guard soldiers' perceived parenting and couple adjustment 1 year following return from Iraq. Method: Participants were 468 Army National Guard fathers from a brigade combat team (mean age = 36 years; median deployment length = 16 months; 89% European American, 5% African American, 6% Hispanic American). Participants completed an in-theater survey 1 month before returning home from Operation Iraqi Freedom deployment (Time 1) and again 1 year postdeployment (Time 2). The PTSD Checklist-Military Version (PCL-M; Weathers, Litz, Herman, Huska, & Keane, 1993) was gathered at both times, and 2 items assessing social support were gathered at baseline only. At Time 2, participants also completed self-report measures of parenting (Alabama Parenting Questionnaire-Short Form; Elgar, Waschbusch, Dadds, & Sigvaldason, 2007), couple adjustment (Dyadic Adjustment Scale-7; Sharpley & Rogers, 1984; Spanier, 1976), parent-child relationship quality (4 items from the Social Adjustment Scale-Self-Report; Weissman & Bothwell, 1976), alcohol use (Alcohol Use Disorders Identification Test; Babor, Higgins-Biddle, Saunders, & Monteiro, 2001), and items assessing injuries sustained while deployed. Results: Structural equation modeling analyses showed that increases in PTSD symptoms were associated with poorer couple adjustment and greater perceived parenting challenges at Time 2 (both at p Language: en

Randomized controlled trial of behavioral activation smoking cessation treatment for smokers with elevated depressive symptoms.

Abstract: Moderately elevated levels of pre-treatment, current depressive symptoms are associated with poor smoking cessation outcomes (e.g., Cinciripini et al., 2003; Niaura et al., 2001). Anti-depressant medications and/or mood specific cognitive behavioral treatments largely have not impacted depressive symptoms during quit attempts (e.g., Kahler et al., 2002) and treatment effects appear unrelated to depressive symptom change (e.g., Piper et al., 2008). Beyond the putative role of depressive symptoms in cessation failure, emerging research indicates a critical role of low positive affect in poor cessation outcomes (e.g., Leventhal et al., 2008; McCarthy et al., 2008) and in deprivation-induced withdrawal and craving (e.g., Cook et al., 2004). Although extant research typically has focused on the role of negative affectivity/mood on cessation failure (c.f., Spring et al., 2008), it remains crucial to consider low positive affect/anhedonia (i.e., reduced positive emotions and a diminished capacity to experience pleasure; Pizzagelli et al., 2005) as these dimensions have also predicted smoking cessation-related changes in withdrawal symptoms and relapse beyond depression history (Leventhal et al., 2008). Behavioral activation (BA; Jacobson et al., 1996; Lejuez et al., 2001) strategies may be a promising adjunct to standard cessation strategies for smokers with elevated depressive symptoms, as this is a brief approach that targets greater contact with more valued environments through systematic efforts to increase rewarding experiences/enjoyment of daily activities, which may simultaneously reduce negative affect and improve positive affect through overt behavior change (Hopko, Lejuez et al., 2003). We conducted a small scale randomized clinical trial of BA strategies with standard cognitive-behavioral smoking cessation strategies including transdermal nicotine patch (BATS). The comparison condition received standard smoking cessation treatment including transdermal nicotine patch (ST), matched for overall contact time. We hypothesized participants in BATS would evidence higher point prevalence abstinence rates at 1, 4, 16, and 26 weeks post assigned quit date, as well as decreased depressive symptoms and enjoyment from daily activities at those time periods.

Motivational interviewing for smoking cessation: a meta-analytic review.

Abstract: Objective: Motivational interviewing (MI) is a treatment approach that has been widely examined as an intervention for tobacco dependence and is recommended in clinical practice guidelines. Previous reviews evaluating the efficacy of MI for smoking cessation noted effects that were modest in magnitude but included few studies. The current study is a comprehensive meta-analysis of MI for smoking cessation. Method: The meta-analysis included 31 controlled trials with an abstinence outcome variable. Studies with nonpregnant (N = 23) and pregnant samples (N = 8) were analyzed separately. Results: For nonpregnant samples, combined results suggest that MI significantly outperformed comparison conditions at long-term follow-up points (d c = .17). The magnitudes of this result represented a 2.3% difference in abstinence rates between MI and comparison groups. All analyses investigating the impact of moderating participant, intervention, and study design characteristics on outcome were nonsignificant, with the exception of studies including international, non-U.S. samples, which had larger effects overall. Several subgroups of studies had significant combined effect sizes, pointing to potentially promising applications of MI, including studies that had participants with young age, medical comorbidities, low tobacco dependence, and, consistent with clinical practice guidelines, low motivation or intent to quit. Effects were smaller among pregnant samples. In addition, significant combined effect sizes were observed among subgroups of studies that administered less than 1 hr of MI and among studies that reported high levels of treatment fidelity. Conclusions: The results are interpreted in light of other behavioral approaches to smoking cessation, and the public health implications of the findings are discussed.

Computer-assisted cognitive behavioral therapy for child anxiety: Results of a randomized clinical trial.

Abstract: Objective This study examined the feasibility, acceptability, and effects of Camp Cope-A-Lot (CCAL), a computer-assisted cognitive behavioral therapy (CBT) for anxiety in youth. Method Children (49; 33 males) ages 7-13 (M = 10.1 ± 1.6; 83.7% Caucasian, 14.2% African American, 2% Hispanic) with a principal anxiety disorder were randomly assigned to (a) CCAL, (b) individual CBT (ICBT), or (c) a computer-assisted education, support, and attention (CESA) condition. All therapists were from the community (school or counseling psychologists, clinical psychologist) or were PsyD or PhD trainees with no experience or training in CBT for child anxiety. Independent diagnostic interviews and self-report measures were completed at pre- and posttreatment and 3-month follow-up. Results At posttreatment, ICBT or CCAL children showed significantly better gains than CESA children; 70%, 81%, and 19%, respectively, no longer met criteria for their principal anxiety diagnosis. Gains were maintained at follow-up, with no significant differences between ICBT and CCAL. Parents and children rated all treatments acceptable, with CCAL and ICBT children rating higher satisfaction than CESA children. Conclusions Findings support the feasibility, acceptability and beneficial effects of CCAL for anxious youth. Discussion considers the potential of computer-assisted treatments in the dissemination of empirically supported treatments.

Randomized trial of MST and ARC in a two-level evidence-based treatment implementation strategy.

Abstract: Objective: A randomized trial assessed the effectiveness of a 2-level strategy for implementing evidence-based mental health treatments for delinquent youth. Method: A 2 × 2 design encompassing 14 rural Appalachian counties included 2 factors: (a) the random assignment of delinquent youth within each county to a multisystemic therapy (MST) program or usual services and (b) the random assignment of counties to the ARC (for availability, responsiveness, and continuity) organizational intervention for implementing effective community-based mental health services. The design created 4 treatment conditions (MST plus ARC, MST only, ARC only, control). Outcome measures for 615 youth who were 69% male, 91% Caucasian, and aged 9―17 years included the Child Behavior Checklist and out-of-home placements. Results: A multilevel, mixed-effects, regression analysis of 6-month treatment outcomes found that youth total problem behavior in the MST plus ARC condition was at a nonclinical level and significantly lower than in other conditions. Total problem behavior was equivalent and at nonclinical levels in all conditions by the 18-month follow-up, but youth in the MST plus ARC condition entered out-of-home placements at a significantly lower rate (16%) than youth in the control condition (34%). Conclusions: Two-level strategies that combine an organizational intervention such as ARC and an evidence-based treatment such as MST are promising approaches to implementing effective community-based mental health services. More research is needed to understand how such strategies can be used effectively in a variety of organizational contexts and with other types of evidence-based treatments.

Mindfulness-Based Cognitive Therapy for Individuals Whose Lives Have Been Affected by Cancer: A Randomized Controlled Trial.

Abstract: Objective This study evaluated the effectiveness of mindfulness-based cognitive therapy (MBCT) for individuals with a diagnosis of cancer. Method Participants (N = 115) diagnosed with cancer, across site and stage, were randomly allocated to either the treatment or the wait-list condition. Treatment was conducted at 1 site, by a single therapist, and involved participation in 8 weekly 2-hr sessions that focused on mindfulness. Participants meditated for up to 1 hr daily and attended an additional full-day session during the course. Participants were assessed before treatment and 10 weeks later; this second assessment occurred immediately after completion of the program for the treatment condition. The treatment condition was also assessed at 3 months postintervention. All postinitial assessments were completed by assessors who were blind to treatment allocation. Results There were large and significant improvements in mindfulness (effect size [ES] = 0.55), depression (ES = 0.83), anxiety (ES = 0.59), and distress (ES = 0.53) as well as a trend for quality of life (ES = 0.30) for MBCT participants compared to those who had not received the training. The wait-list group was assessed before and after receiving the intervention and demonstrated similar change. Conclusions These improvements represent clinically meaningful change and provide evidence for the provision of MBCT within oncology settings.

Cognitive behavioral therapy for 4- to 7-year-old children with anxiety disorders: a randomized clinical trial.

Abstract: Objective: To examine the efficacy of a developmentally appropriate parent–child cognitive behavioraltherapy (CBT) protocol for anxiety disorders in children ages 4–7 years. Method: Design: Randomizedwait-list controlled trial. Conduct: Sixty-four children (53% female, mean age 5.4 years, 80% EuropeanAmerican)withanxietydisorderswererandomizedtoaparent–childCBTintervention( n 34)ora6-monthwait-list condition ( n 30). Children were assessed by interviewers blind to treatment assignment, usingstructured diagnostic interviews with parents, laboratory assessments of behavioral inhibition, and parentquestionnaires. Analysis: Chi-square analyses of outcome rates and linear and ordinal regression of repeatedmeasures, examining time by intervention interactions. Results: The response rate (much or very muchimproved on the Clinical Global Impression Scale for Anxiety) among 57 completers was 69% versus 32%(CBT vs. controls), p .01; intent-to-treat: 59% vs. 30%, p .016. Treated children showed a significantlygreater decrease in anxiety disorders (effect size [ ES ] .55) and increase in parent-rated coping ( ES .69)than controls, as well as significantly better CGI improvement on social phobia/avoidant disorder ( ES .95),separation anxiety disorder ( ES .82), and specific phobia ( ES .78), but not on generalized anxietydisorder. Results on the Child Behavior Checklist Internalizing scale were not significant and were limited bylow return rates. Treatment response was unrelated to age or parental anxiety but was negatively predicted bybehavioral inhibition. Gains were maintained at 1-year follow-up. Conclusions: Results suggest that devel-opmentally modified parent–child CBT may show promise in 4- to 7-year-old children.Keywords: childhood anxiety disorders, cognitive behavioral therapy, preschoolers, behavioral inhibition,randomized clinical trialDina R. Hirshfeld-Becker, Bruce Masek, Aude Henin, Rachel A.Pollock-Wurman, Jerrold F. Rosenbaum, and Joseph Biederman, Depart-ment of Psychiatry, Massachusetts General Hospital, and Department ofPsychiatry, Harvard Medical School; Lauren Raezer Blakely, JuliaMcQuade, Lillian DePetrillo, and Jacquelyn Briesch, Department of Psy-chiatry, Massachusetts General Hospital; Thomas H. Ollendick, Depart-ment of Psychology, Virginia Polytechnic Institute and State University.Lauren Raezer Blakely is now at the Guidance Department, NeedhamPublic School System, Needham, MA; Julia McQuade is now at the Depart-ment of Psychology, University of Vermont; Lillian DePetrillo is now at theDepartmentofPsychology,CatholicUniversity;andJacquelynBrieschisnowat the Department of School Psychology, Northeastern University.This work was supported by National Institutes of Health Grant K08MH001538, awarded to Dina R. Hirshfeld-Becker. The Brandon SheddFund at the Massachusetts General Hospital funded early development ofthe treatment manual. We gratefully acknowledge Jerome Kagan, NancySnidman, Michael Otto, and Michael Monuteaux for their contributions tothis project, as well as Lynette Dufton and Natasha Segool, who assistedwith coordination and coding.Dina R. Hirshfeld-Becker and Aude Henin have received honoraria fromReedMedicalEducation(acompanyworkingasalogisticscollaboratorforthe MGH Psychiatry Academy). The education programs conducted by theMGH Psychiatry Academy were supported, in part, through independentmedical education grants from pharmaceutical companies, includingAstraZeneca, Lilly, McNeil Pediatrics, Janssen, Bristol-Myers Squibb,Shire, Forest Laboratories, Inc., Sanori Advents, and Pfizer. Aude Heninhas received honoraria from Shire, Abbott Laboratories, and the AmericanAcademy of Child and Adolescent Psychiatry. She receives royalties fromOxford University Press. Jerrold F. Rosenbaum served on the advisoryboard of Medavante in 2009, on the advisory boards of Boheringer In-gelheim and Lilly in 2008, and on the advisory board of Organon in 2007.Joseph Biederman is currently receiving research support from the follow-ing sources: Alza, AstraZeneca, Bristol Myers Squibb, Eli Lilly and Co.,JanssenPharmaceuticals,Inc.,McNeil,Merck,Organon,Otsuka,Shire,theNational Institute of Mental Health, and the National Institute of ChildHealth and Human Development. In 2009, he received speaker’s fees fromthe following sources: Fundacion Areces, Medice Pharmaceuticals, and theSpanish Child Psychiatry Association. In previous years, he receivedresearch support, consultation fees, or speaker’s fees for or from thefollowing additional sources: Abbott, AstraZeneca, Celltech, Cephalon, EliLilly and Co., Esai, Forest, Glaxo, Gliatech, Janssen, McNeil, the NationalAlliance for Research on Schizophrenia and Depression, the NationalInstitute on Drug Abuse, New River, Novartis, Noven, Neurosearch,Pfizer, Pharmacia, the Prechter Foundation, Shire, the Stanley Foundation,UCB Pharma, Inc., and Wyeth.Correspondence concerning this article should be addressed to Dina R.Hirshfeld-Becker, Massachusetts General Hospital, 185 Alewife Brook Parkway,Suite 2000, Cambridge, MA 02138. E-mail: dhirshfeld@partners.org

Alcohol and sexual risk behaviors as mediators of the sexual victimization-revictimization relationship.

Abstract: Numerous studies demonstrate a strong relationship between sexual victimization and revictimization. Women who are victimized sexually, whether in childhood (Merrill et al., 1999), adolescence (Hines, 2007; Humphrey & White, 2000) or adulthood (Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997) are at elevated risk of being victimized again. Although several possible explanations for this persistent finding have been offered, there have been few prospective examinations of the proposed mediational mechanisms and hence limited support for any of these models. The current longitudinal study was designed to address this gap by examining the indirect effect of adolescent sexual victimization on later sexual victimization, specifically focusing on risky alcohol use and sexual behavior as potential mediating mechanisms. The empirical link between victimization and revictimization is robust and widely replicated across samples and ages but not well understood. Although empirical tests show a direct relationship, the actual relationship is much more likely to be indirect. That is, early victimization is likely to result in consequences for the woman that increase her vulnerability to later assault. Several integrative reviews have considered a variety of possibilities to explain the robust victimization – revictimization relationship (see Breitenbecher, 2001; Gold, Sinclair, & Balge, 1999; Messman-Moore & Long, 2003; Polusny & Follette, 1995). One explanation is that victims have difficulty assessing or responding to risky situations, and these impaired responses to risky situations increase vulnerability to sexual assault (see Gidycz, McNamara, & Edwards, 2006 for a review). Another explanation is that psychological trauma resulting from early victimization, such as post-traumatic stress, mediates the relationship between initial and later victimization (Hedtke et al., 2008; Risser, Hetzel-Riggin, Thomsen, & McCanne, 2006). Trauma symptoms, such as hyperarousal, may interfere with the ability to correctly recognize danger or may alert potential perpetrators to the woman's vulnerability (see Messman-Moore & Long, 2003). Another proposed mechanism involves self-medication of trauma symptoms through use of alcohol or drugs (see Stewart, Pihl, Conrod, & Dongier, 1998) or engaging in sexual activity as a way of regulating negative affect (Briere, 2005). Both substance use and elevated sexual activity may subsequently increase vulnerability to later victimization. It is this mechanism that is the focus of the current investigation. Numerous studies demonstrate that childhood and adolescent victimization are associated with increased substance use and abuse in adolescence and adulthood (Champion et al., 2004; Epstein, Saunders, Kilpatrick, & Resnick, 1998; Kendler et al., 2000; Kilpatrick, Acierno, Resnick, Best, & Schnurr, 2000; Nelson et al., 2002; Wilsnack, Vogeltanz, Klassen, & Harris, 1997; see Sartor, Agrawal, McCutcheon, Duncan, & Lynskey, 2008 for a review). In turn, women's substance use has been identified as a risk factor for subsequent sexual victimization (Mohler-Kuo, Dowdall, Koss, & Wechsler, 2004; Parks, Hsieh, Bradizza, & Romosz, 2008; Testa, VanZile-Tamsen, & Livingston, 2007). Increased vulnerability associated with alcohol use may stem from several potential mechanisms. First, acute intoxication impairs a women's ability to recognize sexual assault risk while increasing willingness to engage in risk-enhancing behaviors (e.g., Testa, VanZile-Tamsen, Livingston, & Buddie, 2006). At higher levels of intoxication, incapacitation or unconsciousness can result, leaving the woman unable to resist unwanted sexual advances (Kilpatrick, Resnick, Ruggierio, Conoscenti, & McCauley, 2007; Testa, Livingston, VanZile-Tamsen, & Frone, 2003). Among college students, rape while incapacitated is considerably more common than forcible rape (Mohler-Kuo et al, 2004). In addition, young people typically consume alcohol in social settings such as parties and bars where others are drinking (Single & Wortley, 1993). These settings, which include intoxicated males and females in a sexually-laden context (see Norris, Nurius, & Dimeff, 1996) pose risks for sexual victimization independent of alcohol consumption (Copenhaver & Grauerholz, 1991; Parks & Zetes-Zanatta, 1999). Another risk behavior that has been associated with sexual victimization is increased sexual activity. Numerous studies show that childhood sexual abuse (CSA) survivors initiate sex earlier and have more sexual partners than non-survivors (see Arriola, Louden, Doldren, & Fortenberry, 2005; Senn, Carey, & Vanable, 2008 for reviews). Prospective studies have implicated higher levels of consensual sexual activity as a risk factor for later sexual victimization (Messman-Moore, Coates, Gaffey, & Johnson, 2008; Parks, Romosz, Bradizza, & Hsieh, 2008; Raghavan, Bogart, Elliott, Vestal, & Schuster, 2004). The increased vulnerability associated with having more sexual partners may reflect the fact that with exposure to more men, there is a statistically increased chance of encountering an aggressive man. However, it may also reflect greater exposure to parties and other locations that facilitate sexual activity or “hookups, ” just as the sexual vulnerability associated with drinking alcohol may reflect risk associated with the settings in which alcohol is consumed. Flack et al. (2007) found that hookups, that is, brief sexual encounters outside of intimate or dating relationships, were the most common context in which sexual victimization occurred in their sample of college women. Frequency of alcohol intoxication is strongly associated with hooking up (Paul, McManus, & Hayes, 2000). Although mediated models explaining the link between initial and later sexual victimization are often implied (see Filipas & Ullman, 2006; Siegel & Williams, 2003), there are few empirical tests of such models. Gidycz, Hanson and Layman (1995) tested, but failed to find that alcohol or sexual partners mediated the relationship between prior and subsequent victimization in a college sample. However, Orcutt, Cooper, and Garcia (2005) found that the strength of the relationship between prior and subsequent victimization in a community sample was reduced when sexual behavior was considered as a mediator. Substance use was not considered in this study. Thus, a primary goal of this study was to test a mediated model, whereby the relationship between adolescent sexual victimization and college victimization is presumed to be mediated via two types of risky behaviors: sexual and alcohol-related. The transition from high school to college is a particularly appropriate time to examine the mediating influences of risky behaviors on sexual victimization, given that the college setting, with its inherently greater freedoms, offers increased availability and opportunity to engage in risky behavior if one so desires (Fromme, Corbin, & Kruse, 2008). Accordingly, there are well-documented increases in alcohol consumption from high school to college (Schulenberg & Maggs, 2002; White et al., 2006) and some evidence that the likelihood of having sex with multiple partners increases during this transition as well (Fromme et al, 2008). Moreover, the first year of college is a particularly high risk time for sexual victimization relative to later college years (Humphrey & White, 2000). For college students, sexual and alcohol-related risk behaviors are likely to be particularly important (and related) predictors of sexual vulnerability given that heavy episodic drinking and “hookups” occur within the drinking contexts that also pose a risk for sexual victimization. Based on these research findings, we propose and test a prospective, mediated model of revictimization among first year college students (see Figure 1). Consistent with much prior research (e.g., Humphrey & White, 2000), we hypothesize that adolescent sexual victimization will increase risk of experiencing sexual victimization during the first year of college. However, we also expect the victimization-revictimization relationship to be at least partially mediated by alcohol-related and sexual risk behaviors in the first semester of college. Thus, we expect a significant path from high school victimization to college risk behaviors and a significant path from college risk behaviors to college victimization. The proposed model accounts for the expected positive association, at baseline, of adolescent victimization and drinking and sexual activity in the last year of high school. Moreover, the model accounts for the significant association of high school risk behaviors and college risk behaviors (e.g. Fromme et al, 2008; Sher & Rutledge, 2007), with high school HED and sexual activity as additional mediators of the effects of adolescent victimization on college risk exposure. Figure 1 Conceptual prospective model of first semester college risk behaviors as mediators of sexual revictimization during first year of college. T0 is the baseline at the end of senior year in high school; T1 is the end of the first fall semester in college; ...

Efficacy of Web-Based Personalized Normative Feedback: A Two-Year Randomized Controlled Trial

Abstract: Objective Web-based brief alcohol interventions have the potential to reach a large number of individuals at low cost; however, few controlled evaluations have been conducted to date. The present study was designed to evaluate the efficacy of gender-specific versus gender-nonspecific personalized normative feedback (PNF) with single versus biannual administration in a 2-year randomized controlled trial targeting a large sample of heavy-drinking college students.

Prospective Reciprocal Relations between Physical Activity and Depression in Female Adolescents.

Abstract: Objective Although research has found an inverse correlation between physical activity and depression among adolescents, few studies have examined this relation prospectively. Thus, we tested whether physical activity reduces risk for future escalations in depression and whether depression decreases likelihood of future change in physical activity.

Does pretreatment severity moderate the efficacy of psychological treatment of adult outpatient depression? A meta-analysis.

Abstract: Objective: It is widely believed that psychological treatment has little effect on more severely depressed patients. This study assessed whether pretreatment severity moderates psychological treatment outcome relative to controls by means of meta-analyses. Method: We included 132 studies (10,134 participants) from a database of studies (www.evidencebasedpsychotherapies.org) in which the effects of psychological treatment on adult outpatients with a depressive disorder or an elevated level of depressive symptoms were compared with a control condition in a randomized controlled trial. Two raters independently extracted outcome data and rated study characteristics. We conducted metaregression analyses assessing whether mean pretreatment depression scores predicted psychological treatment versus control condition posttreatment effect size and subgroup analyses summarizing the results of studies reporting within-study analyses of depression severity and psychological treatment outcome. Results: Psychological treatment was found to be consistently superior to control conditions (d = 0.40–0.88). We found no indication that pretreatment mean depression scores predicted psychological treatment versus control condition posttreatment effect size, even after adjusting for relevant study characteristics. However, among the smaller subset of studies that reported within-study severity analyses, posttreatment effect sizes were higher for high-severity patients (d = 0.63) than for low-severity patients (d = 0.22) when psychological treatment was efficacious relative to a more stringent control. Conclusion: Contrary to conventional wisdom, our findings suggest that when compared with control conditions, psychological treatment might be more efficacious for high-severity than for low-severity patients. Because the number of studies reporting within-study severity analyses is small, we recommend that future studies routinely report tests for Severity × Treatment interactions.

Coping and parenting: Mediators of 12-month outcomes of a family group cognitive-behavioral preventive intervention with families of depressed parents.

Abstract: In a randomized clinical trial with 111 families of parents with a history of major depressive disorder (86% mothers; 86% Caucasian), changes in adolescents’ (mean age 11 years; 42% female) coping and parents’ parenting skills were examined as mediators of the effects of a family group cognitive behavioral preventive intervention on adolescents’ internalizing and externalizing symptoms. Changes in hypothesized mediators were assessed at 6-months and changes in adolescents’ symptoms were measured at 12-month follow-up. Significant differences favoring the family intervention as compared with a written information comparison condition were found for changes in composite measures of parent-adolescent reports of adolescents’ use of secondary control coping skills and direct observations of parents’ positive parenting skills. Changes in adolescents’ secondary control coping and positive parenting mediated the effects of the intervention on depressive, internalizing and externalizing symptoms accounting for approximately half of the effect of the intervention on the outcomes. Further, reciprocal relations between children’s internalizing symptoms and parenting were found from baseline to 6-month follow-up. Implications for the prevention of psychopathology in offspring of depressed parents are highlighted.

Youth Psychotherapy Change Trajectories and Outcomes in Usual Care: Community Mental Health versus Managed Care Settings.

Abstract: Objective The authors compared symptom change trajectories and treatment outcome categories in children and adolescents receiving routine outpatient mental health services in a public community mental health system and a private managed care organization. Method Archival longitudinal outcome data from parents completing the Youth Outcome Questionnaire (Y-OQ) were retrieved for children and adolescents (4-17 years old) served in a community mental health system (n = 936, mean age = 12 years, 40% girls or young women, 28% from families of color) and a managed care organization (n = 3,075, mean age = 13 years, 45% girls or young women, race and ethnicity not reported). The authors analyzed Y-OQ data using multilevel modeling and partial proportional odds modeling to test for differences in change trajectories and final outcomes across the 2 service settings. Results Although initial symptom level was comparable across the 2 settings, the rate of change was significantly steeper for cases in the managed care setting. In addition, 24% of cases in the community mental health setting demonstrated a significant increase in symptoms over the course of treatment, compared with 14% of cases in the managed care setting. Conclusions These results emphasize the need for increased attention to negative outcomes in routine mental health services and provide a stronger foundation for identifying youth cases at risk for treatment failure. In addition, given the overall differences observed across treatment settings for average rate of change and deterioration rates, results suggest that setting-specific model heuristics should be used for identifying cases at risk for negative outcomes.

Hurricane-related exposure experiences and stressors, other life events, and social support: concurrent and prospective impact on children's persistent posttraumatic stress symptoms.

Abstract: Objective: We investigated the influence of hurricane exposure, stressors occurring during the hurricane and recovery period, and social support on children's persistent posttraumatic stress (PTS). Method: Using a 2-wave, prospective design, we assessed 384 children (54% girls; mean age = 8.74 years) 9 months posthurricane, and we reassessed 245 children 21 months posthurricane. Children completed measures of exposure experiences, social support, hurricane-related stressors, life events, and PTS symptoms. Results: At Time 1, 35% of the children reported moderate to very severe levels of PTS symptoms; at Time 2, this reduced to 29%. Hurricane-related stressors influenced children's persistent PTS symptoms and the occurrence of other life events, which in turn also influenced persistent PTS symptoms. The cascading effects of hurricane stressors and other life events disrupted children's social support over time, which further influenced persistent PTS symptoms. Social support from peers buffered the impact of disaster exposure on children's PTS symptoms. Conclusions: The effects of a destructive hurricane on children's PTS symptoms persisted almost 2 years after the storm. The factors contributing to PTS symptoms are interrelated in complex ways. The findings suggest a need to close the gap between interventions delivered in the immediate and short-term aftermath and those delivered 2 years or more postdisaster. Such interventions might focus on helping children manage disaster-related stressors and other life events as well as bolstering children's support systems. (PsycINFO Database Record (c) 2010 APA, all rights reserved). Language: en

Marital status and satisfaction five years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy.

Abstract: Objective: To follow distressed married couples for 5 years after their participation in a randomized clinical trial. Method: A total of 134 chronically and seriously distressed married couples were randomly assigned to approximately 8 months of either traditional behavioral couple therapy (TBCT; Jacobson & Margolin, 1979) or integrative behavioral couple therapy (IBCT; Jacobson & Christensen, 1998). Marital status and satisfaction were assessed approximately every 3 months during treatment and every 6 months for 5 years after treatment. Results: Pre- to posttreatment effect sizes on marital satisfaction were d 0.90 for IBCT and d 0.71 for TBCT, which were not significantly different. However, data through 2-year follow-ups revealed statistically significant superiority of IBCT over TBCT in relationship satisfaction, but subsequent data showed increasing similarity and nonsignificant differences in outcome. At 5-year follow-up for marital satisfaction relative to pretreatment, effect sizes were d 1.03 for IBCT and d 0.92 for TBCT; 50.0% of IBCT couples and 45.9% of TBCT couples showed clinically significant improvement. Relationship status, obtained on all 134 couples, revealed that 25.7% of IBCT couples and 27.9% of TBCT couples were separated or divorced. These follow-up data compared favorably to other, long-term results of couple therapy. Conclusion: TBCT and IBCT both produced substantial effect sizes in even seriously and chronically distressed couples. IBCT produced significantly but not dramatically superior outcomes through the first 2 years after treatment termination but without further intervention; outcomes for the 2 treatments converged over longer follow-up periods.

A School-Randomized Clinical Trial of an Integrated Social-Emotional Learning and Literacy Intervention: Impacts After 1 School Year

Abstract: Objective To report experimental impacts of a universal, integrated school-based intervention in social-emotional learning and literacy development on change over 1 school year in 3rd-grade children's social-emotional, behavioral, and academic outcomes. Method This study employed a school-randomized, experimental design and included 942 3rd-grade children (49% boys; 45.6% Hispanic/Latino, 41.1% Black/African American, 4.7% non-Hispanic White, and 8.6% other racial/ethnic groups, including Asian, Pacific Islander, Native American) in 18 New York City public elementary schools. Data on children's social-cognitive processes (e.g., hostile attribution biases), behavioral symptomatology (e.g., conduct problems), and literacy skills and academic achievement (e.g., reading achievement) were collected in the fall and spring of 1 school year. Results There were main effects of the 4Rs Program after 1 year on only 2 of the 13 outcomes examined. These include children's self-reports of hostile attributional biases (Cohen's d = 0.20) and depression (d = 0.24). As expected based on program and developmental theory, there were impacts of the intervention for those children identified by teachers at baseline with the highest levels of aggression (d = 0.32-0.59) on 4 other outcomes: children's self-reports of aggressive fantasies, teacher reports of academic skills, reading achievement scaled scores, and children's attendance. Conclusions This report of effects of the 4Rs intervention on individual children across domains of functioning after 1 school year represents an important first step in establishing a better understanding of what is achievable by a schoolwide intervention such as the 4Rs in its earliest stages of unfolding. The first-year impacts, combined with our knowledge of sustained and expanded effects after a second year, provide evidence that this intervention may be initiating positive developmental cascades both in the general population of students and among those at highest behavioral risk. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Psychiatric disorders and sexual risk among adolescents in mental health treatment.

Abstract: In the United States, youth under age 25 account for nearly half of newly diagnosed sexually transmitted infections (STIs) annually, including HIV (CDC, 2005). Youth with psychiatric disorders or with a history of psychiatric hospitalizations initiate intercourse at an earlier age, are less likely to use condoms, have higher rates of STIs, have more unintended pregnancies, and have more sexual partners than adolescents without a history of mental illness (Baker & Mossman, 1991; DiClemente & Ponton, 1993; Valois, Bryant, Rivard, & Hinkle, 1997). The Social Personal Framework is a broad contextual model that posits the important role of personal attributes, peer /partner factors, family influences and the community in determining risk. It accounts for the increased risk among youth with psychiatric disorders by emphasizing the unique role of psychopathology (a personal attribute) because of its association with factors such as impulsivity, lack of judgment, cognitive misperception, sensitivity to partner rejection, sexual trauma and low self-esteem (Donenberg & Pao, 2005). Although psychopathology in general is associated with sexual risk, few studies have examined the relationship between groupings of disorders and risk. This project sought to extend previous research by documenting the additional risk associated with internalizing, externalizing, co-morbid disorders and Mania, compared to those adolescents who did not meet criteria but were in mental health treatment. Some psychiatric disorders may be more strongly associated with sexual risk than others because of differences in behaviors or attitudes (e.g., impulsivity associated with Conduct Disorder and ADHD; poor self-esteem associated with Depressive Disorders). Cross-sectional studies indicate that externalizing behaviors are linked with early sexual debut and failure to use condoms, and the association between internalizing behaviors and sexual risk behavior is inconsistent (Abrantes, Strong, Ramsey, Kazura, & Brown, 2006; Auslander et al., 2002; Donenberg, Bryant, Emerson, Wilson, & Pasch, 2003; Lehrer, Shrier, Gortmaker SL, & Buka, 2006; Lescano, Brown, Hadley, D'Eramo, & Zimskind, 2007; Mazzaferro et al., 2006; Rhode, Noell, Ochs, & Seeley, 2001; Shrier, Harris, Sternberg, & Beardslee, 2001; Waller et al., 2006). Some longitudinal studies suggest that symptoms of conduct disorder/antisocial behavior during childhood and adolescence are the best predictor of sexual risk behaviors during adulthood (Ramrakha et al., 2007). Other studies suggest that adolescent symptoms of anxiety, post-traumatic stress, and depression are predictive of sexual risk behavior as an adult (Stiffman, Dore, Earls, & Cunningham, 1992). We are not aware of any studies that have examined the association of Mania and sexual risk behavior in adolescents. Among adults, a history of Mania is consistently associated with sexual risk behavior, such as high rates of sexual activity, sex with prostitutes, and low rates of condom use (Meade, Graff, Griffin, & Weiss, 2008; Ramrakha, Caspi, Dickson, Moffitt, & Paul, 2000; Sacks, Dermatis, Burton, Hull, & Perry, 1994). Although Mania and Hypomania are not uncommon among adolescents, especially for youth in intensive treatment settings, the association with sexual risk behavior has not been rigorously examined. The current study used a structured computer interview to examine the relationship between psychiatric disorders (i.e., Major Depressive (MDD), Mania, Hypomania, Generalized Anxiety (GAD), Post Traumatic Stress (PTSD), Conduct (CD), Attention Deficit Hyperactivity (ADHD) and Oppositional Defiant Disorders (ODD)) and sexual risk behaviors. Adolescents meeting criteria were compared to adolescents who did not meet criteria but were in mental health treatment. This analysis accounts for the general factors associated with the need for treatment such as stress, impairment and family dysfunction. Factors, such as the presence of alcohol use and gender, could influence sexual risk and were assessed and adjusted for in tests of risk association. We hypothesized that a lifetime or recent occurrence of vaginal/anal sex, lack of condom use at last sex, number of partners and the presence of a STI would be associated with Mania and/or Hypomania and with disorders commonly thought of as externalizing disorders (CD, ODD, and ADHD) because of characteristic impulsivity and recklessness associated with these disorders (Brown, Lourie, Zlotnick, & Cohn, 2000). We did not have a priori hypotheses for internalizing disorders (MDD, GAD, and PTSD) and their relationships with sexual risk behavior because previous studies have yielded conflicting results.

Psychiatric Disorders in Smokers Seeking Treatment for Tobacco Dependence: Relations with Tobacco Dependence and Cessation.

Abstract: Objective: The present research examined the relation of psychiatric disorders to tobacco dependence and cessation outcomes. Method: Data were collected from 1,504 smokers (58.2% women; 83.9% White; mean age = 44.67 years, SD = 11.08) making an aided smoking cessation attempt as part of a clinical trial. Psychiatric diagnoses were determined with the Composite International Diagnostic Interview structured clinical interview. Tobacco dependence was assessed with the Fagerstrom Test of Nicotine Dependence (FTND) and the Wisconsin Inventory of Smoking Dependence Motives (WISDM). Results: Diagnostic groups included those who were never diagnosed, those who had ever been diagnosed (at any time, including in the past year), and those with past-year diagnoses (with or without prior diagnosis). Some diagnostic groups had lower follow-up abstinence rates than did the never diagnosed group (ps < .05). At 8 weeks after quitting, strong associations were found between cessation outcome and both past-year mood disorder and ever diagnosed anxiety disorder. At 6 months after quitting, those ever diagnosed with an anxiety disorder (OR = .72, p = .02) and those ever diagnosed with more than one psychiatric diagnosis (OR = .74, p = .03) had lower abstinence rates. The diagnostic categories did not differ in smoking heaviness or the FTND, but they did differ in dependence motives assessed with the WISDM. Conclusion: Information on recent or lifetime psychiatric disorders may help clinicians gauge relapse risk and may suggest dependence motives that are particularly relevant to affected patients. These findings also illustrate the importance of using multidimensional tobacco dependence assessments.

Suicidal, Abused African American Women's Response to a Culturally Informed Intervention

Abstract: Objective: This study examined (a) the efficacy of a manualized, culturally informed, empowerment-focused psychoeducational group intervention (Nia) designed in accord with the theory of triadic influence or treatment as usual (TAU) for reducing psychological symptomatology (suicidal ideation, depressive symptoms, posttraumatic stress symptoms, general psychological distress), and (b) the effect of Nia versus TAU on the relation between exposure to intimate partner violence (IPV) and psychological symptomatology in these women. Method: Two hundred eight low-socioeconomic-status African American women with a recent history of IPV and a suicide attempt were randomized to Nia or TAU and assessed at baseline, postintervention, and 6- and 12-month follow-up. They were assessed on their levels of IPV (Index of Spouse Abuse), suicidal ideation (Beck Scale for Suicidal Ideation), depressive symptoms (Beck Depression Inventory-II), posttraumatic stress symptoms, and general psychological distress (Brief Symptom Inventory). Results:Hierarchical linear modeling found that women receiving the culturally informed Nia intervention showed more rapid reductions in depressive symptoms and general distress initially, and the between-group difference in depressive symptoms persisted at follow-up. Following intervention, compared with women randomized to TAU, women in Nia exhibited less severe suicidal ideation when exposed to physical and nonphysical IPV. Conclusions:Findings highlight the value of incorporating Nia as an adjunctive intervention for abused, suicidal, low-income women. They underscore the ways the intervention needs to be bolstered to address more directly more mediating and moderating constructs, as well as the need to target more effectively the key outcomes. Language: en

Trauma, binge eating, and the "strong Black woman".

Abstract: Objective The primary goal of this study was to test a culturally specific model of binge eating in African American female trauma survivors, investigating potential mechanisms through which trauma exposure and distress were related to binge eating symptomatology. Method Participants were 179 African American female trauma survivors who completed questionnaires about traumatic experiences; emotional inhibition/regulation difficulties; self-silencing (prioritizing others' needs and adopting external self-evaluation standards); eating for psychological reasons; binge eating; and internalization of "Strong Black Woman" (SBW) ideology, an important cultural symbol emphasizing strength and self-sufficiency. Results Structural path analysis supported the proposed model in which SBW ideology, emotional inhibition/regulation difficulties, and eating for psychological reasons mediated the relationship between trauma exposure/distress and binge eating. The proposed model provided better fit to the data than several competing models. Conclusions These findings suggest that among African American trauma survivors, trauma exposure and distress predict greater internalization of SBW ideology, which is associated with emotional inhibition/regulation difficulties, eating for psychological reasons, and ultimately binge eating. Implications of these findings for assessment, treatment, and prevention efforts are discussed.

Impact of race on early treatment termination and outcomes in posttraumatic stress disorder treatment.

Abstract: Objective:The present study investigated the influence of race on posttraumatic stress disorder (PTSD) treatment among 94 African American and 214 Caucasian female victims of interpersonal violence participating in 2 studies of cognitive-behavioral treatment for PTSD that were conducted sequentially and continuously. Method:In each study, participants were randomized into 1of 3 conditions. The first study compared cognitive processing therapy with prolonged exposure and a delayed treatment condition. In the second study, cognitive processing therapy was compared with its constituent components: cognitive therapy only and written accounts. Participants were assessed with the Clinician Administered PTSD Scale and the Structured Clinical Interview for DSM-IV, as well as through self-report measures of PTSD. Results:Analyses revealed that African Americans were significantly less likely to complete treatment compared with Caucasians (45% vs. 73%, respectively, p Language: en

Understanding factors associated with early therapeutic alliance in PTSD treatment: adherence, childhood sexual abuse history, and social support.

Abstract: Objective: Therapeutic alliance has been associated with better treatment engagement, better adherence, and less dropout across various treatments and disorders. In treatment of posttraumatic stress disorder (PTSD), it may be particularly important to establish a strong early alliance to facilitate treatment adherence. However, factors such as childhood sexual abuse (CSA) history and poor social support may impede the development of early alliance in those receiving PTSD treatment. We sought to examine treatment adherence, CSA history, and social support as factors associated with early alliance in individuals with chronic PTSD who were receiving either prolonged exposure therapy (PE) or sertraline. Method: At pretreatment, participants (76.6% female; 64.9% Caucasian; mean age 37.1 years, SD 11.3) completed measures of trauma history, general support (Inventory of Socially Supportive Behaviors), and trauma-related social support (Social Reactions Questionnaire). Over the course of 10 weeks of PE or sertraline, they completed early therapeutic alliance (Working Alliance Inventory) and treatment adherence measures. Results: Early alliance was associated with PE adherence (r .32, p .05) and overall treatment completion (r .19, p .05). Only trauma-related social support predicted the strength of early alliance beyond the effects of treatment condition ( .23, p .05); CSA history was not predictive of a lower early alliance. Conclusions: Given the associations with adherence, clinicians may find it useful to routinely assess alliance early in treatment. Positive trauma support, not CSA history, may be particularly important in the development of a strong early therapeutic alliance.