PTSD Out-of-the-Box: Using Principles not Protocols (November 2023)

Course Overview

PTSD is a chronic and disabling condition with high comorbidity, distressing symptoms, and far-reaching negative effects (Rosemary et al., 2016, Goodson et al. 2011; Kline et al, 2021). PTSD sufferers experience internal distress, intimate relationship difficulties, social isolation, occupational problems, family disruption, and diminished quality of life (Paulus & Aupperle, 2015; Rosemnary et al. 2016; Yu et al 2016; Hernandez-Tejada et al., 2017; Sripada et al, 2018; Campbell and Renshaw, 2018, Creech and Misca, 2017,).

Fortunately, several evidence-based treatments exist and have been widely disseminated (Eftekahri et al. 2013; Chard et al. 2012). Large organizations such as the VHA have invested significant amounts of money and resources to train a large number of their providers in EBPs. In particular, by 2020 the number of VA providers trained in an EBP was estimated to be 11,600 with costs per provider and site estimated to be $1,485 and $43,000, respectively (Valenstein-Mah et al., 2020). This widescale training initiative have benefited thousands of veterans with PTSD whom have receiving an evidence-based treatment. Helping support this assertion are a growing number of treatment outcome studies have found large treatment effects for veterans with PTSD wo undergo EBPs (Goodson et al., 2017; Jeffrey et al., 2014; Shnurr et al., 2022).

However, while EBPs have flourished and come to be considered the gold-standard for PTSD treatment, several concerns have emerged. Research has consistently shown large drop-out rates ranging from 16% (Yoder et al., 30134) to 55 % (Schnurr et al., 2022). Further, those studies with lower drop-out rates have often used less stringent criteria for treatment completion (e.g., 6 sessions of PE) (Tuerk et al., 2011). In addition to high dropouts, 30-50 %of individuals do not respond with significant symptom reduction (Marmar, 2015). In fact, upwards of 40 percent of veterans who complete an EBP for PTSD continue to suffer with unchanged symptoms (Galsgaard & Eskelund, 2020; 2020; Schottenbauer et al. 2008). Similarly, anywhere from 32-72% of EBP completers do not achieve PTSD remission (they continue to retain the diagnosis of PTSD) (Steenkamp et al., 2015). Thus, it appears as if sole reliance on EBPs may lead to suboptimal treatment responses in a substantial minority of individuals with PTSD.

The purpose of this training is not to devalue EBPs. In fact, the author has been a PE trainer and consultant for the past 15 years and published several treatment outcomes studies it's effectiveness. However, it seems important to consider a broader range of interventions when it becomes clear that an EBP is not resulting in the desired symptom reduction. Most providers who treat PTSD can recall patients who dropped out or had a poor treatment response. It would seemingly be beneficial to have a broader set of tools (i.e., interventions) to bring to bear when patients are not responding. These interventions should be rooted in evidence but not necessarily a fixed protocol.

Several factors may lead to a less optimal fit for a PTSD EBP, including: lack of buy-in/motivation, difficulty tolerating high levels of distress with exposure, mismatch between most troubling symptoms and focus of EBPs, multiple traumatic events, negative beliefs about PTSD and treatment, positive beliefs about PTSD symptoms, rumination (vs intrusive memories, and difficulties learning cognitive restructuring). For each of these factors, specific treatment interventions will be discussed and key components in evidence-informed sessions will be presented. Further, a conceptual model of treatment-relevant factors will be presented. This model allows for multiple points of intervention. In addition, alternative measures to capture quality of life changes, changes in safety behaviors, changes in intrusions, changes in functional outcomes and others will be presented. Finally, illustrative examples of treatment cases who did not respond to EBP protocols but then had excellent responses to alternative, evidence-informed interventions will be presented.

Participants will be provided with useful treatment materials for evidence-informed interventions and a resource list for such interventions and/or treatments. The training will consist of lecture, group discussion, experiential exercises, and discussion of a conceptual model to help guide intervention selection. The duration of the training will be four hours.

Learning Objectives

Course Bibliography

Approvals

Approvals:

Cognitive Behavior Institute, #1771, is approved as an ACE provider to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Regulatory boards are the final authority on courses accepted for continuing education credit. ACE provider approval period: 06/30/2022-06/30/2025. Social workers completing this course receive 4 clinical continuing education credits.

Cognitive Behavior Institute, LLC is recognized by the New York State Education Department's State Board for Psychology as an approved provider of continuing education for licensed psychologists #PSY-0098 and the State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0646 and the State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors #MHC-0216.

Cognitive Behavior Institute has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 7117. Programs that do not qualify for NBCC credit are clearly identified. Cognitive Behavior Institute is solely responsible for all aspects of the programs.

Cognitive Behavior Institute is approved by the American Psychological Association to sponsor continuing education for psychologists. Cognitive Behavior Institute maintains responsibility for content of this program. Social workers, marriage and family therapists, and professional counselors in Pennsylvania can receive continuing education from providers approved by the American Psychological Association. Since CBI is approved by the American Psychological Association to sponsor continuing education, licensed social workers, licensed marriage and family therapists, and licensed professional counselors in Pennsylvania will be able to fulfill their continuing education requirements by attending CBI continuing education programs. For professionals outside the state of Pennsylvania, you must confirm with your specific State Board that APA approved CE's are accepted towards your licensure requirements. The Association of Social Work Boards (ASWB) has a process for approving individual programs or providers for continuing education through their Approved Continuing Education (ACE) program. ACE approved providers and individual courses approved by ASWB are not accepted by every state and regulatory board for continuing education credits for social workers. Every US state other than New York accepts ACE approval for social workers in some capacity: New Jersey only accepts individually approved courses for social workers, rather than courses from approved providers. The West Virginia board requires board approval for live courses, but accepts ASWB ACE approval for other courses for social workers. For more information, please see https://www.aswb.org/ace/ace-jurisdiction-map/. Whether or not boards accept ASWB ACE approved continuing education for other professionals such as licensed professional counselors or licensed marriage and family therapists varies by jurisdiction. To determine if a course can be accepted by your licensing board, please review your board’s regulations or contact them. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit.

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