Cognitive-behavioral therapy (CBT) typically comprises psychoeducation, anxiety management, stress inoculation, cognitive restructuring, imaginal and in vivo exposure, and relapse prevention. Although there is considerable evidence for the efficacy of CBT in reducing PTSD symptoms in people with chronic PTSD (for reviews, see Bryant & Friedman, 2001; Foa & Meadows, 1997; Foa, 2001; Harvey, Bryant, & Tarrier, 2002), there is a limited evidence base for early interventions using CBT. Apart from uncontrolled studies of early interventions that employed some CBT approaches (Brom, Kleber, & Hofman, 1993; Viney, Clark, Bunn, & Benjamin, 1985), the first attempts at controlled study of early intervention applied behavioral approaches. Kilpat-rick and Veronen (1984) randomly allocated 15 recent rape victims to either repeated assessments, delayed assessment, or a brief behavioral intervention that comprised a 4- to 6-hour program that involved imaginal reliving of the trauma, education about psychological responses to trauma, cognitive restructuring, and anxiety management. The brief intervention was no more effective than the repeated assessments. This study was limited, however, by small sample sizes, the lack of rigorous application of exposure, and ambiguity about the degree of psychopathology experienced after the rape (Kilpat-rick & Calhoun, 1988).
Foa and colleagues conducted a more rigorous study by providing brief CBT to victims of sexual and nonsexual assault shortly after the trauma (Foa, Hearst-Ikeda, & Perry, 1995). This study compared participants who received CBT (including exposure, anxiety management, in vivo exposure, and cognitive restructuring) to matched participants who received repeated assessments. Each participant received four treatment sessions and then received assessment by blind assessors at 2 months posttreatment and at 5-month follow-up. Whereas 10% of the CBT group met criteria for PTSD at 2 months, 70% of the control group met criteria; there were no differences between groups at 5 months, although the CBT group was less depressed. This study suggests that CBT may accelerate natural recovery from trauma. Inferences from this study were limited, however, by the lack of random assignment. In a subsequent study, Foa, Zoellner, and Feeny (2002) randomly allocated survivors of assault who met criteria for PTSD in the initial weeks after the assault to four weekly sessions of CBT, repeated assessment, or supportive counseling (SC). At posttreatment, patients in the CBT and repeated-assessment conditions showed comparable improvements. SC was associated with greater PTSD severity and greater general anxiety than the CBT group. At 9-month follow-up, approximately 30% of participants in each group met criteria for PTSD.
A potential limitation of these studies is that the inclusion of all recently distressed trauma survivors raises the possibility that treatment effects may overlap with natural recovery in the initial months after trauma exposure. In an attempt to overcome this problem, other studies have focused on people who meet criteria for ASD because of evidence that most people who do display ASD are at high risk for subsequent PTSD (Bryant, 2003). In an initial study of ASD participants, Bryant and colleagues randomly allocated motor vehicle accident or nonsexual assault survivors with ASD to either CBT or SC (Bryant, Harvey, Dang, Sackville, & Basten, 1998b). Both interventions consisted of five 1.5-hour weekly individual therapy sessions. CBT included education about posttraumatic reactions, relaxation training, cognitive restructuring, and imaginal and in vivo exposure to the traumatic event. The SC condition included trauma education and more general problem-solving skills training in the context of an unconditionally supportive relationship. At the 6-month follow-up, fewer participants in the CBT group (20%) met diagnostic criteria for PTSD, compared to SC control participants (67%). In a subsequent study that dismantled the components of CBT, 45 civilian trauma survivors with ASD were randomly allocated to five sessions of either (1) prolonged exposure, cognitive therapy, anxiety management; (2) prolonged exposure and cognitive therapy; or (3) SC (Bryant, Sackville, Dang, Moulds, & Guthrie, 1999). This study found that at the 6-month follow-up, PTSD was observed in approximately 20% of both active treatment groups compared to 67% of those receiving SC. A follow-up of participants who completed these two treatment studies indicated that the treatment gains of those who received CBT were maintained 4 years after treatment (Bryant, Moulds, & Nixon, 2003b).
Two recent studies by the same research group have supported the utility of CBT for people with ASD. One study randomly allocated civilian trauma survivors (N = 89) with ASD to either CBT, CBT associated with hypnosis, or SC (Bryant, Moulds, Guthrie, & Nixon, 2005). This study added hypnosis to CBT because some commentators have argued that hypnosis may breach dissociative symptoms that characterize ASD (Spiegel, 1996). To this end, the hypnosis component was provided immediately prior to imaginal exposure in an attempt to facilitate emotional processing of the trauma memories. In terms of treatment completers, more participants in the SC condition (57%) met PTSD criteria at 6-month follow-up than those in the CBT (21%) or CBT + hypnosis (22%) condition. Interestingly, participants in the CBT + hypnosis condition reported greater reduction of reexperiencing symptoms at posttreatment than those in the CBT condition. This finding suggests that hypnosis may facilitate treatment gains in ASD
participants. Finally, a recent study replicated the original Bryant et al. (1998b) study with a sample of ASD participants (N = 24) who had sustained mild traumatic brain injury following motor vehicle accidents (Bryant et al., 2003a). This study investigated the efficacy of CBT in people who lost consciousness during the trauma as result of their injury. consistent with the previous studies, fewer participants receiving CBT (8%) met criteria for PTSD at 6-month follow-up than those receiving SC (58%).
Gidron et al. (2001) provided a two-session CBT intervention that was intended to promote memory reconstruction in 17 survivors of accidents. This approach was based on the premise that facilitating people's organization of trauma memories would assist processing of these memories and thereby assist recovery. using an entry criterion of a heart rate higher than 94 beats per minute at admission to the emergency room (see Bryant et al., 2000a; Shalev et al., 1998), participants in this study received a telephone-administered protocol 1-3 days after the accident. Patients who received this intervention had greater reductions in severity of PTSD symptoms 3-4 months after the trauma than did those who received two sessions of supportive listening over the telephone.
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