Trauma-Focused Psychotherapy and PTSD
Today, I present a single study (that is available full-text) related to trauma and PTSD. Keyan, Garland, Choi-Christou, Tran, O'Donnell & Bryant (2024) published “A Systematic Review and Meta-Analysis of Predictors of Response to Trauma-Focused Psychotherapy for Posttraumatic Stress Disorder” in Psychological Bulletin. Here are excerpts from the abstract, public significance statement, and conclusion:
Although trauma-focused psychotherapy (T-F psychotherapy) is the treatment of choice for posttraumatic stress disorder (PTSD), up to one half of patients do not respond to this treatment.
Attempts to improve response to T-F psychotherapy have focused on augmenting fear extinction-based factors. Here, a systematic and meta-analytic review of predictors of T-F psychotherapy outcome was conducted with the goal of using an aggregate data-driven approach to elucidate baseline factors associated with treatment outcome. There were 114 studies that met inclusion criteria (N = 61, 970; Mage = 40.1 years; 40.1% female). There were 237 effect sizes across 24 meta-analytic categories. Poorer treatment response is associated with lower pretreatment levels of activation of fear-related brain regions, psychophysiological reactivity to fear provocation, trauma-related cognitions, anger, depression, high-risk alleles of genes linked to fear, lower levels of executive control, and social support. A range of other factors also predicted poorer responses including being male, non-Caucasian, older in age, early trauma occurrence, more trauma experience, history of combat trauma, as well as comorbid sleep, pain, poor quality life, and alcohol abuse difficulties. This review provides one potential explanation for the limited success of T-F psychotherapy augmentation strategies that have focused only on fear circuity mechanisms at the exclusion of other factors. Here, poor response relating to predictors of early trauma onset and comorbidity are consistent with clinical presentations of complex PTSD, which may suggest T-F psychotherapy is less effective for this condition. This collective evidence suggests that clinicians should consider a tailored approach that targets potential barriers to successful treatment response.
Although many of these findings are correlational rather than causal in nature, and they were considered in isolation rather than in combination, these findings suggest there is a need to consider a broader range of candidates to augment treatment response. Clinicians may improve treatment response by addressing these potential barriers to optimal therapy outcome.
In the context of many patients not responding to T-F psychotherapy, which is the treatment of choice for PTSD, this review points to several key conclusions. First, the current finding that factors related to extinction are an important predictor of treatment response underscores the importance of exposure therapy and is consistent with T-F psychotherapy being a frontline treatment for PTSD. This suggests that pharmacological and psychological strategies focused on extinction processes are worthy of ongoing investigation. Second, the review indicated that there are multiple other factors that can influence a person’s response to T-F interventions that do not seemingly involve fear or extinction mechanisms. Many people with PTSD may require a broader approach to optimizing treatment response by targeting these other risk factors for poor treatment outcomes. The success rate of T-F psychotherapy has not improved over four decades, and this barrier may require a more comprehensive approach to treatments by targeting the range of factors that are associated with limited successful outcomes. A likely interpretation of the current findings is that the optimal approach to treating PTSD does not involve a “one-size fits all” solution but may require a more personalized approach that addresses specific issues that a patient may have that are likely to interfere with treatment success. While recognizing that identifying risk factors for poor treatment response does not necessarily indicate causative change mechanisms that occur in treatment, both clinicians and researchers may achieve their goals more effectively by assessing factors that are predictive of treatment response, which may lead to more informed targeting of potential candidates that may influence treatment response.
I thought this was an important study of trauma-focused therapy, which is regularly recommended. I especially like the conclusion about the danger of a one-size-fits-all solution.