Abstract
Background: Although there are effective treatments for posttraumatic stress disorder (PTSD), there is little research on treatments with non-cognitive-behavioural backgrounds, such as gestalt therapy. We tested an integrative gestalt-derived intervention, dialogical exposure therapy (DET), against an established cognitive-behavioural treatment (cognitive processing therapy, CPT) for possible differential effects in terms of symptomatic outcome and drop-out rates. Methods: We randomized 141 treatment-seeking individuals with a diagnosis of PTSD to receive either DET or CPT. Therapy length in both treatments was flexible with a maximum duration of 24 sessions. Results: Dropout rates were 12.2% in DET and 14.9% in CPT. Patients in both conditions achieved significant and large reductions in PTSD symptoms (Impact of Event Scale - Revised; Hedges' g = 1.14 for DET and d = 1.57 for CPT) which were largely stable at the 6-month follow-up. At the posttreatment assessment, CPT performed statistically better than DET on symptom and cognition measures. For several outcome measures, younger patients profited better from CPT than older ones, while there was no age effect for DET. Conclusions: Our results indicate that DET merits further research and may be an alternative to established treatments for PTSD. It remains to be seen whether DET confers advantages in areas of functioning beyond PTSD symptoms.
References
1.
Bisson J, Andrew M: Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev 2009;1:1-48.
2.
Cloitre M: Effective psychotherapies for posttraumatic stress disorder: a review and critique. CNS Spectr 2009;14:32-43.
3.
Bisson JI, Ehlers A, Matthews R, Pilling S, Richards D, Turner S: Psychological treatments for chronic post-traumatic stress disorder. Systematic review and meta-analysis. Br J Psychiatry 2007;190:97-104.
4.
Bradley R, Greene J, Russ E, Dutra L, Westen D: A multidimensional meta-analysis of psychotherapy for PTSD. Am J Psychiatry 2005;162:214-227.
5.
Seidler GH, Wagner FE: Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study. Psychol Med 2006;36:1515-1522.
6.
Watts BV, Schnurr PP, Mayo L, Young-Xu Y, Weeks WB, Friedman MJ: Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. J Clin Psychiatry 2013;74:e541-e550.
7.
National Institute for Health and Care Excellence: Posttraumatic Stress Disorder. The Management of PTSD in Adults and Children in Primary and Secondary Care. CG26. London, NICE, 2005.
8.
Centre for Posttraumatic Mental Health: Australian Guidelines for the Treatment of Adults with Acute Stress Disorder and Posttraumatic Stress Disorder. Melbourne, ACPMH, 2007.
9.
American Psychiatric Association: Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder. Washington, APA, 2010.
10.
Schnyder U: Why new psychotherapies for posttraumatic stress disorder? Psychother Psychosom 2005;74:199-201.
11.
Van Emmerik AAP, Kamphuis JH, Emmelkamp PMG: Treating acute and posttraumatic stress disorder with cognitive behavioral therapy or structured writing therapy: a randomized controlled trial. Psychother Psychosom 2008;77:93-100.
12.
Kersting A, Dölemeyer R, Steinig J, Walter F, Kroker K, Baust K, Wagner B: Brief internet-based intervention reduces posttraumatic stress and prolonged grief in parents after the loss of a child during pregnancy: a randomized controlled trial. Psychother Psychosom 2013;82:372-381.
13.
Jung K, Steil R: A randomized controlled trial on cognitive restructuring and imagery modification to reduce the feeling of being contaminated in adult survivors of childhood sexual abuse suffering from posttraumatic stress disorder. Psychother Psychosom 2013;82:213-220.
14.
Nickerson A, Schnyder U, Bryant RA, Schick M, Mueller J, Morina N: Moral injury in traumatized refugees. Psychother Psychosom 2015;84:122-123.
15.
Jacob N, Neuner F, Maedl A, Schaal S, Elbert T: Dissemination of psychotherapy for trauma spectrum disorders in postconflict settings: a randomized controlled trial in Rwanda. Psychother Psychosom 2014;83:354-363.
16.
Paivio SC, Greenberg LS: Resolving ‘unfinished business': efficacy of experiential therapy using empty-chair dialogue. J Consult Clin Psychol 1995;63:419-425.
17.
Paivio SC, Nieuwenhuis JA: Efficacy of emotion focused therapy for adult survivors of child abuse: a preliminary study. J Trauma Stress 2001;14:115-133.
18.
Rosner R, Henkel C: Die Gestalttherapie in der Psychotraumatologie - Charakteristika und Wirksamkeit gestalttherapeutischer Interventionen bei posttraumatischen Belastungsstörungen (Gestalt therapy in psycho-traumatology - characteristics and efficacy of gestalt interventions for posttraumatic stress disorder). Trauma Gewalt 2010;4:294-303.
19.
Imel ZE, Laska K, Jakupcak M, Simpson TL: Meta-analysis of dropout in treatments for posttraumatic stress disorder. J Consult Clin Psychol 2013;81:394-404.
20.
Yontef GM: Awareness, Dialogue and Process: Essays on Gestalt Therapy. Gouldsboro, Gestalt Journal Press, 1993.
21.
Butollo W, Hagl M, Krüsmann M: Kreativität und Destruktion posttraumatischer Bewältigung (Creativity and Destruction in Posttraumatic Coping). Munich, Pfeiffer, 1999.
22.
Butollo W, Karl R, König J, Hagl M: Dialogical exposure in a gestalt-based treatment for posttraumatic stress disorder. Gestalt Review 2014;18:112-129.
23.
Hagl M, Powell S, Rosner R, Butollo W: Dialogical exposure with traumatically bereaved Bosnian women: findings from a controlled trial. Clin Psychol Psychother DOI: 10.1002/cpp.1921.
24.
Sloan DM, Feinstein BA, Gallagher MW, Beck J, Keane TM: Efficacy of group treatment for posttraumatic stress disorder symptoms: a meta-analysis. Psychol Trauma Theory Res Pract Policy 2013;5:175-183.
25.
Butollo W, König J, Karl R, Henkel C, Rosner R: Feasibility and outcome of dialogical exposure therapy for posttraumatic stress disorder. Psychother Res 2014;24:514-521.
26.
Maercker A, Schützwohl M: Erfassung von psychischen Belastungsfolgen: die Impact of Event Skala - revidierte Version (IES-R) [Measurement of psychological sequelae of stress: the Impact of Event Scale - Revised (IES-R)]. Diagnostica 1998;44:130-141.
27.
Foa EB, Cashman L, Jaycox L, Perry K: The validation of a self-report measure of posttraumatic stress disorder: the Posttraumatic Diagnostic Scale. Psychol Assess 1997;9:446-451.
28.
Resick PA, Monson CM, Chard KM: Cognitive Processing Therapy: Veteran/Military Version. Washington, Department of Veterans' Affairs, 2007.
29.
Faul F, Erdfelder E, Lang AG, Buchner A: G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 2007;39:175-191.
30.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4. Washington, APA, 1994.
31.
Hiller W, Zaudig M, Mombour W: IDCL Internationale Diagnosen Checklisten für DSM-IV und ICD-10 (IDCL International Diagnostic Checklists for DSM-IV and ICD-10). Göttingen, Hogrefe, 1996.
32.
Wittchen HU, Pfister H: Diagnostisches Expertensystem für psychische Störungen (DIA-X) [Diagnostic System for Psychiatric Disorders for Experts (DIA-X)]. Frankfurt, Swets & Zeitlinger, 1997.
33.
Wittchen HU, Lachner G, Wunderlich U. Pfister H: Test-retest reliability of the computerized DSM-IV version of the Munich-Composite International Diagnostic Interview (M-CIDI). Soc Psychiatry Psychiatr Epidemiol 1998;33:568-578.
34.
Strauss B, Schumacher J: Klinische Interviews und Ratingskalen (Clinical Interviews and Rating Scales). Göttingen, Hogrefe, 2005.
35.
Wittchen HU, Zaudig M, Fydrich T: Strukturiertes klinisches Interview für DSM-IV (SKID) [Structured Clinical Interview for DSM-IV (SCID)]. Göttingen, Hogrefe, 1997.
36.
Weiss D, Marmar C: The Impact of Event Scale-Revised; in Wilson J, Keane T (eds): Assessing Psychological Trauma and PTSD. New York, Guilford, 1997, pp 168-189.
37.
Griesel D, Wessa M, Flor H: Psychometric qualities of the German version of the Posttraumatic Diagnostic Scale (PTDS). Psychol Assess 2006;18:262-268.
38.
Ehring T, Kleim B, Clark DM, Foa EB, Ehlers A: Screening for posttraumatic stress disorder. What combination of symptoms predicts best? J Nerv Ment Dis 2007;195:1004-1012.
39.
Derogatis LR, Melisaratos N: The Brief Symptom Inventory: an introductory report. Psychol Med 1983;13:595-605.
40.
Franke GH: Brief Symptom Inventory von L.R. Derogatis (Kurzform der SCL-90-R) - deutsche Version [Brief Symptom Inventory by L.R. Derogatis (short version of the SCL-90-R) - German Version]. Göttingen, Beltz Test GmbH, 2002.
41.
Geisheim C, Hahlweg K, Fiegenbaum W, Frank M, Schröder B, von Witzleben I: Das Brief Symptom Inventory (BSI) als Instrument zur Qualitätssicherung in der Psychotherapie [The Brief Symptom Inventory (BSI) as an instrument of quality management in psychotherapy]. Diagnostica 2002;48:28-36.
42.
Foa EB, Ehlers A, Clark DM, Tolin DF, Orsillo SM: The Posttraumatic Cognitions Inventory (PTCI): development and validation. Psychol Assess1999;11:303-314.
43.
Horowitz L, Strauss B, Kordy H: Inventar zur Erfassung interpersonaler Probleme - deutsche Version (IIP-D) [Inventory of Interpersonal Problems - German Version (IIP-D)]. Weinheim, Beltz Test GmbH, 1994.
44.
Horowitz LM, Rosenberg SE, Baer BA, Ureño G, Villaseñor VS: Inventory of Interpersonal Problems: psychometric properties and clinical applications. J Consult Clin Psychol 1988;56:885-892.
45.
Schmitt M, Maes J, Schmal A: Gerechtigkeit als innerdeutsches Problem: Auswahl von Indikatoren seelischer Gesundheit (Justice as a problem in unified Germany: selection of indicators of mental health). Fachbereich I - Psychologie, Universität Trier, 1995. http://www.gerechtigkeitsforschung.de/berichte/beri080.pdf (accessed August 13, 2013).
46.
Fahrenberg J, Myrtek M, Wilk D, Kreutel K: Multimodale Erfassung der Lebenszufriedenheit: eine Untersuchung an Koronarkranken (Multimodal measurement of life satisfaction: a study of patients with coronary disease). Psychother Psychosom Med Psychol 1986;36:347-354.
47.
Butollo W, Karl R: Dialogische Traumatherapie. Ein Manual zur Behandlung der posttraumatischen Belastungsstörung (Dialogical Exposure Therapy. A Treatment Manual for Posttraumatic Stress Disorder). Stuttgart, Klett-Cotta, 2012.
48.
König J, Resick PA, Karl R, Rosner R: Posttraumatische Belastungsstörung. Ein Manual zur Cognitive Processing Therapy (Posttraumatic Stress Disorder. A Manual for Cognitive Processing Therapy). Göttingen, Hogrefe, 2012.
49.
Plouffe KA: Paraprofessional intervention utilizing a cognitive processing therapy protocol. Clin Case Stud 2007;6:348-361.
50.
Klauer JK: Handbuch kognitives Training (Handbook Cognitive Training). Göttingen, Hogrefe, 2001.
51.
Lenhart A: Mittelwertsunterschiede zweier verschieden grosser Gruppen im Prä-Post-Design (dkorr nach Klauer, 2001) [Mean differences between two groups of different sizes in a pre-post design (dkorr according to Klauer, 2001)]. http://www.psychometrica.de/effektstaerke.html (accessed April 3, 2015).
52.
Brähler E, Horowitz LM, Kordy H, Schumacher J, Strauss B: Zur Validierung des Inventars zur Erfassung Interpersonaler Probleme (IIP) - Ergebnisse einer Repräsentativbefragung in Ost- und Westdeutschland [Validation of the Inventory of Interpersonal Problems (IIP) - results of a representative survey in Eastern and Western Germany]. Psychother Psychosom Med Psychol 1999;49:422-431.
53.
Cohen J: A power primer. Psychol Bull 1992;112:155-159.
54.
Jacobson NS, Truax P: Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol 1991;59:12-19.
55.
König J, Karl R, Rosner R, Butollo W: Sudden gains in two therapies for posttraumatic stress disorder. Behav Res Ther 2014;60:15-22.
56.
Rizvi SL, Vogt DS, Resick PA: Cognitive and affective predictors of treatment outcome in cognitive processing therapy and prolonged exposure for posttraumatic stress disorder. Behav Res Ther 2009;47:737-743.
57.
König J, Onnen M, Karl R, Rosner R, Butollo W: Interpersonal subtypes and therapy response in patients treated for posttraumatic stress disorder. Clin Psychol Psychother 2015, Epub ahead of print.
58.
Resick PA, Nishith P, Weaver TL, Astin MC, Feuer CA: A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. J Consult Clin Psychol 2002;70:867-879.
59.
Resick PA, Galovski TE, Uhlmansiek MO, Scher CD, Clum GA, Young-Xu Y: A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. J Consult Clin Psychol 2008;76:243-258.
© 2015 S. Karger AG, Basel
2015
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.
