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The study ‘Randomized Trial of Cognitive-Behavioral Therapy for Chronic Post-Traumatic Stress Disorders in Adult Female Survivors of Childhood Sexual Abuse’ purposed to compare the efficacy of three treatment strategies – the cognitive-behavioral therapy (CBT), the present-centered therapy (PCT) and the wait-list (WL) – on women with posttraumatic stress disorder (PTSD) arising from childhood sexual abuse.
The nature of the problem discussed in the study therefore revolves around developing proper treatment methodologies for victims of childhood sexual abuse (CSA) who developed PTSD due to their perceived inadequacies to overcome the trauma related to CSA.
Previous controlled trials had adequately revealed the effectiveness of individual CBT for men exhibiting combat-related PTSD, women with PTSD resulting from rape ordeals, and women exhibiting symptoms of PTSD arising from sexual and nonsexual assaults (McDonagh et al 515).
Previous studies had also demonstrated the efficacy of CBT on men and women with PTSD arising from a multiplicity of traumas. A previous study employing the wait-list (WL) had also provided preliminary verification that WL was effective in imaginal exposure heralded by affect-regulation and interpersonal efficacy skills training on adult females (McDonagh et al 516).
However, in spite of the fact that there exist a wealth of clinical literature on treatment methodologies of victims of sexual abuse, the evidence base concerning the treatment of victims of childhood sexual abuse (CSA) exhibiting symptoms of PTSD is considerably limited.
The current research therefore aimed to add critical knowledge on which treatment methodology, between CBT, PCT, and WL is most effective in the treatment of women with PTSD arising from childhood sexual abuse.
As such, the authors came up with a hypothesis that “…CBT would be more effective than PCT and WL in (a) reducing interviewer-rated PTSD symptoms; (b) reducing self-reported depressive, anxiety, dissociative, and anger symptoms, as well as cognitive distortions; and (c) improving quality of life” (McDonagh et al 516).
The independent variables included: History of childhood sexual abuse, demonstration of some intrusive and avoidance symptoms of PTSD directly related to childhood sexual abuse, gender (women), and demonstration of one comprehensible and detailed memory of childhood sexual abuse.
The dependent variables included: Intensity and frequency of PTSD symptoms, coexisting Axis 1 and Axis 2 disorders, depression, level of disruptions of beliefs about self and others, level of dissociative symptomatology, level of state anxiety, state and trait anger, and quality of life.
According to McDonagh et al “…both the CBT and PCT treatments were operationalized in manuals and conducted in 14 individual sessions, the first 7 of which were 2 hr long, and the final 7 of which were 1.5 hr long” (518).
The longer than 1-hr treatment sessions were intended to provide the interviewers with adequate time to elucidate attenuation of anxiety in participants during exposure sessions. After undergoing a rigorous training exercise, distinct groups of female clinicians were charged with the responsibility of providing CBT and PCT treatments to participants.
All therapy sessions were tape-recorded for later review by an expert in the treatment. The participants assigned to the WL treatment were advised that they could obtain their preference of the two treatment strategies in about 14 weeks after they had successfully completed the post-WL evaluation.
In addition to meeting the compulsory requirements for the independent variables mentioned above, the74 women who were selected to take part in the study had to meet some set standards or criteria, namely: non-current use of medication that have considerable effect to the autonomic nervous system; currently not pregnant; no known cardiovascular condition, free from conditions such as mania, hypomania, severe depression, schizoaffective disorder and other related disorders; free from alcohol or drug abuse; no withdrawal symptoms associated with benzodiazepines, alcohol or drug use three months prior to the consideration for enrollment into the study; absence of active suicidal orientation; and absence of an abusive relationship with an intimate partner (McDonagh 516).
As already mentioned, treatment groups were divided into three – cognitive-behavioral therapy (CBT), present-centered therapy (PCT), and wait-list (WL).
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The fundamental components in the treatment procedures for CBT included PE, in vivo exposure and CR, not mentioning that imaginal exposure was commenced in the fourth week of treatment involving attempting to remember the traumatic event with much clarity as possible, recitation of the traumatic event to the clinical therapist in the present tense, and constantly going over the memory until the anxiety or distress subsidized (McDonagh 518).
Psycho-education was also provided to the participants. Treatment protocols for PCT were specifically designed to describe an active therapeutic intervention that could be employed by non-CBT clinicians in the effective treatment of PTSD-CSA. Treatment procedures for WL revolved around the wait-times.
Dependent variables were measure using a wide array of data gathering tools, including: CAPS; SCID; ELS; The Beck Depression Inventory; The Spielberger State-Anxiety Inventory; The Traumatic Stress Institute Beliefs Scale; The Dissociative Experiences Scale; The Cock-Medley Hostility Scale; The State-Trait Anger Expressive Inventory; and The Quality of Life Inventory (McDonagh et al 517).
There was a significant dropout rate in the course of the study, standing at 23 percent. Analysis revealed that PTSD severity as measured by CAPS did not vary between CBT dropouts and those who completed the study, but statistically significant variations were reported on all the other psychometric measures.
It is of if importance to note that the CBT dropouts citied high levels of depression, anxiety and low quality life than those who completed the treatments (McDonagh et al 519). In terms of intention-to-treat analysis, 27.6 percent of subjects in CBT, three in ten in PCT, and about 17.4 percent in WL no longer met the standards set for PTSD. Post hoc analysis of the TSI and CAPS demonstrated that participants in CBT and PCT improved considerably when compared to those in WL.
A follow-up analysis taken three months after treatment demonstrated that 82.4 percent of subjects enrolled in CBT and 42.1 percent enrolled in PCT no longer met standards for PTSD, implying that had developed adequate coping and problem-solving strategies to deal with their distress. At 6-month follow-up, just above three-quarters (76.5 percent) of subjects in CBT and 42.1% in PCT no longer met the criteria for PTSD.
McDonagh and colleagues also found out that “…on measures of anxiety, depression, dissociation, anger, hostility, and cognitive distortions, CBT was comparable with PCT at all post-therapy assessments” (519).
The researchers’ hypothesis that CBT would be more effective than both PCT and WL received consistent support across the various measures employed to evaluate posttraumatic and related symptomatology.
However, the findings came up with new knowledge that PCT is consistently more effective in treating PTSD than WL when measured using the scales explained above. According to McDonagh et al, “…both treatments resulted in marked improvements in PTSD symptom severity, state anxiety, and trauma-related cognitive schemas, all of which showed little change for the WL participants” (520).
It should be noted that both CBT and PCT never proved their superiority over WL in terms of curtailing symptoms of depression, dissociation, aggression, anger, and enhancing the quality of life. All in all, a conclusion can be made that CBT has a considerable positive impact on the treatment of PTSD symptoms for adult female victims of CSA, but the high dropout rate in CBT brings in another dimension that women were more unwilling to complete CBT than other treatment procedures.
The study also adds to our current knowledge by demonstrating that the effectiveness and tolerability of PCT, which utilizes education on the impact of trauma and facilitation of learning skills to enhance social coping strategies, may be an effective non-CBT strategy towards the treatment of PTSD that is largely viewed to be secondary to CSA (McDonagh et al 522). The study was decisively limited by the considerable dropouts especially in CBT
The study utilized scientific procedures to reach a conclusion that CBT was still the treatment of choice for PTSD symptoms related to CSA. However, it must be noted that PCT demonstrated remarkable results in the treatment of PTSD symptoms secondary to CSA and, thus, it should be included in conventional treatment methodologies for PTSD. By and large, the methodologies adopted for the study were able to adequately test the initial hypothesis.
However, it must be said that the researchers employed many measurement procedures that are likely to confuse readers. It is my personal belief that the consistent findings could be achieved through the employment of a few standardized measures. However, future research is needed to demonstrate why many women survivors of CSA opt out of CBT and instead prefer PCT.
McDonagh, A., McHugo, G., Sengupta, A., Demment, C.C., Schnurr, P.P., Friedman, M., Ford J., Mueser, K., Fournier, D., & Descamps, M. Randomized Trial of Cognitive-Behavioral Therapy for Chronic Post-Traumatic Stress Disorder in Adult Female Survivors of Childhood Sexual Abuse. Journal of Consulting and Clinical Psychology 73.3 (2005): 515-524