1. Post Traumatic Stress Disorder We can offer better help … if we know how Reg Nixon Associate Professor, School of Psychology Flinders University 18 February 2014

2. ‘My heart’s desire had been that I alone should perish…here at Troy; that you should sail…[home].’ – Achilles, standing above Patroklos’s corpse (The Illiad, Homer; translation cited in Shay, 1991).
Homer around 860BC

3. It wasn't so bad because I wasn't physically injured
I should have said ‘no’ more
People are dangerous
People can't be trusted
Something terrible will happen again
I can't protect myself
I am damaged
Sexual assault victim, 2013
Female, 39 years old
Sexually assaulted by one (potentially more) males when she was 25 - Was at a pub with some friends, met someone and got on his motorcycle to go for a ride – next moment she came to in a shed surrounded by a group of men. Remembers being dragged around and being physically and sexually (although memory hazy). Remembers seeing knives and bats. Believes she was drugged.
At the time of the assault she had a you child and not long after she had another child. Following sexual assault entered a DV relationship – had left this relationship when she entered therapy
PCL start: 64
PCL end: 17
Blame start: 100%
Blame end: 0%
Before CPT (stuck point from sessions 1 – 5)
I should not have been dancing
I should not have gotten onto his bike
I shouldn't have had anything to drink
I shouldn't have been so nice
I must have lead him on by being friendly
It didn't really happen because I can't remember it
It wasn't so bad because I wasn't physically injured
I should have fought back more
I should have said no more
People are dangerous
people will hurt you if you let your guard down
People can't be trusted
Something terrible will happen again
I can't protect myself
I am damaged
End of CPT
I did nothing to deserve this
I did not bring about this event - he did it
I did everything I could do
This was a significant event but I can cope with it
I am a good person and a good mother
I can be happy and bubbly and this does not lead someone one
I am brave and strong
People are generally trustworthy
Most people are good
I can let my guard down and I will be ok
I can choose who I enter a relationship with and when I want to end that relationship
I am adequate and important
- noted feeling confident, happy and brave at the end of therapy

4. Trauma exposure 75% (Australia)
PTSD prevalence 6.4% (12-month, Australia)
79-85% have a comorbid disorder
PTSD individuals have times the health costs of those without PTSD
At best, only 50% have received treatment, could be as low as 8%
Relative to other anxiety disorders, sufferers:
Have higher health costs
Lower quality of life
Are 2nd only to Agoraphobia in work loss days
Have more suicidal ideation and attempts, even after prior mood disorder is controlled
Trauma exposure 75% (Mills et al., 2011)
PTSD prevalence 6.4% (12-month, Slade et al., 2009)
Comorbidity a major issue (79-85% Creamer et al., 2001; Kessler et al., 1995)
PTSD individuals have times the health costs of those without PTSD (Chan et al., 2003)
These costs are higher than other anxiety disorders (Greenberg et al., 1999; associated with lower quality of life than other anxiety disorders, Olatunji et al., 2007) and 2nd to Agoraphobia in work loss days, Alonso et al., 2004)
Suicide rates etc. Controlling for prior mood disorders, of the anxiety disorders, PTSD is most associated with suicidal ideation and attempts, Sareen et al., 2005)
Spence 2011 – 49% of internet survey with probable PTSD hadn’t received treatment.
Slade 2009 wellbeing survey – only 37% of those with an anxiety disorder had received treatment in prior 12mths.
Wang 2005 – US NCS-R – only 34% of those with PTSD saw a mental health professional
Olesen 2010 – 39% of people with anx/depress saw professional, but only 8-14% saw a mental health professional

5. Cochrane Review / Bisson (2005, 2013) ISTSS / Foa et al., (2009)
TF-CBT ✔
EMDR ✔
Cochrane Review / Bisson (2005, 2013)
ISTSS / Foa et al., (2009)
ACPMH Guidelines (2007)
NICE (2005)
Released August 2013

6. Effective Treatments Are Not Always Used for PTSD
Note in Becker study that 17% of general clinicians not using IE, but 66% of trauma specialists were.
Russell & Silver – 90% of VA and military clinicians NOT using CT, EMDR, Exposure or SIT
Rosen et al – survey in 1999 and 2001 – PE rarely used. Less than 10% of generalist or specialists using manualised therapy, and not PE
Van Minnen et al 2010 – trauma experts, use of IE and EMDR – 4/10 and 5/10, where 1= never use, 10 = always.
Becker, Zayfert, & Anderson, 2004

7. Rosen et al., 2004; Russell & Silver, 2007.
Note in Becker study that 17% of general clinicians not using IE, but 66% of trauma specialists were.
Russell & Silver – 90% of VA and military clinicians NOT using CT, EMDR, Exposure or SIT
Rosen et al – survey of VA clinicians in 1999 and 2001 – PE rarely used. Less than 10% of generalist or specialists using manualised therapy, and not PE
Van Minnen et al 2010 – trauma experts, use of IE and EMDR – 4/10 and 5/10, where 1= never use, 10 = always.
Rosen et al., 2004; Russell & Silver, 2007.

8. Always Not at all van Minnen et al., 2010
Note in Becker study that 17% of general clinicians not using IE, but 66% of trauma specialists were.
Russell & Silver – 90% of VA and military clinicians NOT using CT, EMDR, Exposure or SIT
Rosen et al – survey of VA clinicians in 1999 and 2001 – PE rarely used. Less than 10% of generalist or specialists using manualised therapy, and not PE
Van Minnen et al 2010 – trauma experts, use of IE and EMDR – 4/10 and 5/10, where 1= never use, 10 = always.
van Minnen et al., 2010

9. Some critical factors for successful dissemination, implementation and sustained practice change

10. Practitioner Pre-existing skills
Beliefs, esp. re: evidence-based practice, and beliefs specific to trauma-focussed therapy
Some of the factors above are general and apply to any dissemination effort, some are trauma-focussed
Cited in Ruzek & Rosen (2009). Gray, et al. Elhai, and Schmidt (2007) surveyed members of the ISTSS and other trauma professionals to examine attitudes towards evidence-based practice (EBP): a perceived lack of generalizability of the literature to their client population (36.4%), and inability to apply current research findings to patients with unique characteristics (29.3%) accounts for a signification proportion of perceived barriers.
We know NOW that TF-CBT can be used with psychosis, BPD, other comorbidity, for multiple trauma types etc. etc.
Cook et al. 2004; Couineau & Forbes, 2011; Ruzek & Rosen, 2009.

11. Stand alone versus ongoing consult/support, format of training
Accessibility, cost
Stand alone versus ongoing consult/support, format of training
Availability of supervisors etc.
Cook et al. 2004; Couineau & Forbes, 2011; Ruzek & Rosen, 2009.

12. Trauma-informed (including screening and assessment)
System
Trauma-informed (including screening and assessment)
Group cohesiveness
Leadership
Practical – staffing levels, resources, waiting lists
Cook et al. 2004; Couineau & Forbes, 2011; Ruzek & Rosen, 2009.

13. Recent Initiatives in Australia
Step 1 – Does TF-CBT actually work in routine clinical settings?
Yarrow Place – effectiveness trial
Veterans and Veterans Families Counselling Service (VVCS) – effectiveness trial
Step 2 – If so, how to make it routine practice (sustainability)
VVCS – dissemination project
Australian Defence Force – dissemination project

14. Yarrow Place - Recent Sexual Assault Survivors
Cognitive Processing Therapy (CPT) compared to Treatment as Usual (TAU)
CPT clinicians – 3 day workshop, then weekly consultation
CPT = 6 x 90min sessions
TAU = TAU
N.B. No significant differences between groups in terms of therapeutic alliance.

15. PTSD Checklist (PCL) Cut-off
8-11 TAU continue to have further sessions versus 1 CPT between post-3mths
d = -0.10
d = 0.30
d = 0.16
d = 0.13
d = 0.32
Cut-off
Cut-offs of between have been proposed for PCL depending on military vs. civilian trauma. Also, remember that pre-treatment is ASD window – likely to be quite symptomatic
Generally results showed main effects of time but not group, nor interactions
Within group changes from pre to 12-month FU
CPT: 1.25
TAU: 0.88
Others intervals ranged from 0.95 to 1.05 for CPT, and 0.76 to 0.82 for TAU
Intent-to-treat sample

16. Results – % achieving good end-state functioning1
At 12mths 50% vs 31%
1Good end-state functioning defined as < 20 on the Clinician-Administered PTSD Scale

17. VVCS Effectiveness Trial
Cognitive Processing Therapy (CPT) compared to Treatment as Usual (TAU)
CPT clinicians – workshop, then weekly consultation
CPT = 12 sessions
TAU = TAU
N.B. No significant differences between groups in therapeutic working alliance
(70% VV, 10% Timor, 5% Iraq/Afghanistan)
CPT 10 vs TAU 8 sessions, but when controlled didn’t change outcome
Forbes, Lloyd, Nixon et al., 2012, J Anxiety Disorders.

18. Again, snapshot at a point in time
CPT as implemented, TAU as it usually occurs.

19. Treatment Outcomes - PTSD (3 months follow-up)
CPT:
67% had clinically significant improvements
38% no longer met DSM criterion for PTSD
27% achieved good end-state functioning (remission)
TAU:
35% had clinically significant improvements
13% no longer met DSM criterion for PTSD
3% achieved good end-state functioning
CPT had 10 v’s 8 sessions. But that difference is not big enough to account for the magnitude of the effect.

20. VVCS Dissemination A focus on sustainability
Organizational readiness to implement the intervention
e.g., reducing case loads to allow CPT preparation time: short-term service pain for long-term client and service gain
Monitoring
e.g., embedding PCL into electronic clinical records
Supervisors and deputy directors took part in workshop and consultation
[Less consult than RCT– fortnightly for 6-month period]
Two booster workshops following consultation process

21. Preliminary findings:
Large effect of treatment
Clinician adherence to CPT protocol good (~80%)
CPT Competence – 88% of sessions rated satisfactory or better (i.e., good/very good/excellent)
47% of clients fell below cut-off in an average of 8 sessions.
d = 1.02

22. Australian Defence Force
Ongoing Dissemination Project:
Clients are active duty personnel
Mixture of military and non-military trauma presentations
Training - workshop, 3-months weekly consultation, 3-months fortnightly consultation

23. Preliminary findings

24. Where to from here?

25. Where to from here? Research, training and treatment Policy
Optimal but most cost-efficient training methods
How to overcome barriers to dissemination (individual, organisational etc.)
TF-CBT supervisors – how to retain the knowledge
Long-term assessment of implementation required (skills and quality of treatment maintained?)
Policy
Emphasis on cost-benefit analysis of improved treatment methods
Issakidis et al 2004 – modelling showed that if evidence based care used in Australia, wouldn’t cost more per se but result in better outcomes from averted ‘years lived with a disability’.

26. And if we get research, training, and policy right
Ok, maybe we can’t help Achilles…

27. And if we get research, training, and policy right
Before therapy:
I should have fought back more
People are dangerous
People will hurt you if you let your guard down
People can't be trusted
Something terrible will happen again
I can't protect myself
I am damaged
[PCL = 64]
After therapy:
I did nothing to deserve this
I did not bring about this event - he did it
I did everything I could do
This was a significant event but I can cope with it
I am a good person and a good mother
I am brave and strong
Most people are good
[PCL = 17]
Therapist: Samantha Angelakis

28. Acknowledgments Clients and staff: Flinders staff and students
Yarrow Place
VVCS
ADF
Victim Support Service
Flinders staff and students
Talitha Best, Lisa Beatty, Sarah Wilksch, Samantha Angelakis, Nathan Weber
Collaborators
David Forbes, Delyth Lloyd, Dzenana Kartal, Anne-Laure Couineau, Meaghan O’Donnell, Richard Bryant
Funding agencies
Australian Rotary Health Research Foundation,
Department of Veterans’ Affairs,
Flinders University

29. Questions?