Presentation on theme: "Post Traumatic Stress Disorder We can offer better help … if we know how Reg Nixon Associate Professor, School of Psychology Flinders University 18 February."— Presentation transcript:
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
‘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).
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
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 2 nd only to Agoraphobia in work loss days –Have more suicidal ideation and attempts, even after prior mood disorder is controlled
TF-CBT ✔ EMDR ✔ Cochrane Review / Bisson (2005, 2013) ISTSS / Foa et al., (2009) ACPMH Guidelines (2007) NICE (2005) Released August 2013
Effective Treatments Are Not Always Used for PTSD Becker, Zayfert, & Anderson, 2004
Rosen et al., 2004; Russell & Silver, 2007.
van Minnen et al., 2010 Not at all Always
Some critical factors for successful dissemination, implementation and sustained practice change
Practitioner Pre-existing skills Beliefs, esp. re: evidence-based practice, and beliefs specific to trauma-focussed therapy Cook et al. 2004; Couineau & Forbes, 2011; Ruzek & Rosen, 2009.
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.
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.
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
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.
PTSD Checklist (PCL) Cut-off d = 0.16d = 0.32 d = d = 0.30 d = TAU continue to have further sessions versus 1 CPT between post-3mths Intent-to-treat sample
Results – % achieving good end-state functioning 1 1 Good end-state functioning defined as < 20 on the Clinician-Administered PTSD Scale
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 Forbes, Lloyd, Nixon et al., 2012, J Anxiety Disorders.
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
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
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
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
Where to from here?
Research, training and treatment –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
And if we get research, training, and policy right Ok, maybe we can’t help Achilles…
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
Acknowledgments Clients and staff: 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