Trauma-focused Cognitive Behavioral Therapy Research Articles

Interventions for Adolescent Suicide Ideation and Suicide Attempts in Latin America and Spain: A Systematic Review

Purpose: Adolescents are particularly vulnerable to suicide attempts, which is a major risk factor for completed suicide in this age group. However, most research on suicide prevention interventions comes from high-income countries with predominantly white participants and English protocols. This study examines interventions that have been tested in Latin America and Spain. Methods: A systematic review was conducted to include interventions aimed at reducing suicide ideation, attempts, and increasing knowledge about it in these regions. Results: Sixteen articles were selected, and Dialectical Behaviour Therapy, Problem Solving Therapy, and Trauma-Focused Cognitive Behavioural Therapy were found to be more effective than standard treatments or wait-list conditions in reducing the outcomes. Discussion: This review highlights the need for more research on preventive interventions in Latin America and Spain. While all interventions evaluated were effective, further research and replication studies are necessary to strengthen the evidence base for these interventions.

Post-Traumatic Stress Disorder in Unaccompanied Refugee Minors: Prevalence, Contributing and Protective Factors, and Effective Interventions: A Scoping Review.

In 2021, there were close to 37 million children displaced worldwide. There were 13.7 million refugees and an additional 22.8 million internally displaced. In Europe, this included 23,255 unaccompanied minors seeking asylum, up 72% compared with 2020 (13,550). The objective was to review the current literature regarding PTSD in unaccompanied refugee minors (URM). The authors searched Ovid Medline, Embase, and Cochrane Library from 1 January 2008 through 15 January 2019. Thirty full texts were chosen that specifically studied unaccompanied refugee minors (URM). The results showed that URM had a prevalence of post-traumatic stress disorder (PTSD of 17-85% across the studies reviewed. There were numerous factors that contributed to PTSD, including cumulative stress and trauma, guilt, shame, and uncertainty about legal status. Protective factors included resilience, a trusted mentor, belonging to a social network, religion, having an adult mentor, and having a family (even if far away). Immigrant youth can thrive most easily in multiculturally affirming countries. Five interventions demonstrated effectiveness, comprising trauma-focused cognitive behavioral therapy (TF-CBT); "Mein Weg", a TF-CBT combined with a group-processing mixed therapy approach; teaching recovery techniques (TRT), narrative exposure therapy for children (KIDNET), and expressive arts intervention (EXIT). The significant mental health conditions include depression, anxiety, internalizing and externalizing behaviors, and frequently PTSD. It is fair to conclude that the high levels of mental health problems experienced in URM are due to exposure to traumatic experiences, separation from parents, and lack of social support.

Co-developed implementation guidelines to maximize acceptability, feasibility, and usability of mobile phone supervision in Kenya.

Opportunities exist to leverage mobile phones to replace or supplement in-person supervision of lay counselors. However, contextual variables, such as network connectivity and provider preferences, must be considered. Using an iterative and mixed methods approach, we co-developed implementation guidelines to support the implementation of mobile phone supervision with lay counselors and supervisors delivering a culturally adapted trauma-focused cognitive behavioral therapy in Western Kenya. Guidelines were shared and discussed with lay counselors in educational outreach visits led by supervisors. We evaluated the impact of guidelines and outreach on the acceptability, feasibility, and usability of mobile phone supervision. Guidelines were associated with significant improvements in acceptability and usability of mobile phone supervision. There was no evidence of a significant difference in feasibility. Qualitative interviews with lay counselors and supervisors contextualized how guidelines impacted acceptability and feasibility - by setting expectations for mobile phone supervision, emphasizing importance, increasing comfort, and sharing strategies to improve mobile phone supervision. Introducing and discussing co-developed implementation guidelines significantly improved the acceptability and usability of mobile phone supervision. This approach may provide a flexible and scalable model to address challenges with implementing evidence-based practices and implementation strategies in lower-resourced areas.

TF-CBT Training Augmented with a Self-Care Focus: Understanding Facilitators and Barriers to Treatment Implementation.

Clinicians working with youth exposed to trauma may be at increased risk for experiencing elevated levels of stress and symptoms of secondary traumatic stress, which can negatively impact clinician wellbeing and ultimately contribute to reduced access to quality care for clients. An innovative Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) training incorporating self-care practices (i.e., Practice What You Preach; PWYP) was developed to help facilitate the implementation of TF-CBT and to enhance clinicians' coping and decrease stress. The primary purpose of this study was to determine whether the PWYP-augmented training met three Objectives: (1) increase clinicians' feelings of TF-CBT competency; (2) improve clinicians' coping abilities/reduce clinicians' stress; and (3) increase clinicians' insight into the benefits and/or challenges clients may experience in treatment. An exploratory aim was also developed to identify additional facilitators and barriers of TF-CBT implementation. The written reflections of 86 community-based clinicians who participated in the PWYP-augmented TF-CBT training were examined using qualitative methods. The majority of clinicians indicated increased feelings of competency and improved coping abilities and/or stress levels; almost half mentioned increased insight into clients' experiences. The most frequently mentioned additional facilitators were related to elements of the TF-CBT treatment model. Anxiety/self-doubt was the barrier most frequently mentioned, though all clinicians who mentioned this barrier indicated it lessened or resolved over the course of the training. Incorporating self-care strategies into trainings may serve as a facilitator for TF-CBT implementation by enhancing the competency and well-being of clinicians. The additional insights into barriers and facilitators can be used to further improve the PWYP initiative and future training and implementation efforts.

Bidirectional effects of parental and adolescent symptom change in trauma-focused cognitive behavioral therapy.

The current study examines dynamic, bidirectional associations between parent and adolescent symptom improvement in response to children's therapy for posttraumatic stress disorder (PTSD). Data were collected from a racially and ethnically heterogeneous sample of 1,807 adolescents (age 13-18 years old; 69% female) and a parent participating in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) at a community outpatient behavioral health clinic. Parents self-reported their depressive symptoms and youth self-reported their PTSD and depressive symptoms at the onset of treatment and every three months for up to nine months. Using a bivariate dual change score model (BDCSM) we examine: (a) individual dyad members' change in symptoms and (b) the bidirectional associations between changes in the parent's and youth's symptoms across treatment. Parents' and adolescents' symptoms at the start of treatment were correlated and both parents' and adolescents' symptoms decreased over the course of treatment. Parents' elevated depressive symptoms at each time point contributed to smaller decreases in their children's PTSD and depressive symptoms at the subsequent time point. Adolescents' elevated symptoms at each time point contributed to greater decreases in their parents' symptoms at the subsequent time point. These findings highlight the impact that parents and children have on each other's response to children's trauma-focused psychotherapy. Notably, parents' depressive symptoms appeared to slow their children's progress in treatment, suggesting that attending to parents' symptoms and providing them with supportive services may be an important adjunct to children's interventions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Structural equation modeling of treatment-related changes in neural connectivity for youth with PTSD

BackgroundPrevious studies suggest that improvement in symptoms of posttraumatic stress disorder (PTSD) is accompanied by changes in neural connectivity, however, few studies have investigated directional (effective) connectivity. The current study assesses treatment-related changes in effective connectivity in youth with PTSD undergoing Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). MethodsFunctional MRI scans before and after 16 weeks of TF-CBT for 20 youth with PTSD, or the same time interval for 20 healthy controls (HC) were included in the analysis. Structural equation modeling was used to model group differences in directional connectivity at baseline, and changes in connectivity from pre- to post-treatment. ResultsAt baseline, the PTSD group, relative to the HC group, had significantly greater connectivity in the path from dorsal cingulate to anterior cingulate and from dorsal cingulate to posterior cingulate corticies. From pre- to post-treatment, connectivity in these paths decreased significantly in the PTSD group, as did connectivity from right hippocampus to left superior temporal gyrus. Connectivity from the left amygdala to the lateral orbital frontal cortex was significantly lower in PTSD vs HC at baseline, but did not change from pre- to post-treatment. ConclusionAlthough based on a small sample, these results converge with previous studies in suggesting a central role for the dorsal cingulate cortex in PTSD symptoms. The direction of this connectivity suggests that the dorsal cingulate is the source of modulation of anterior and posterior cingulate cortex during trauma-focused cognitive behavioral therapy.

Group trauma focused cognitive behavior therapy for parents of premature infants compared to individual therapy intervention

BackgroundThe current study compares results of a group-based intervention developed to reduce symptoms of posttraumatic stress, depression, and anxiety in parents of premature infants with a prior study using an individual version of the treatment manual. Methods26 mothers of preterm infants (25–34 weeks' gestational age; >600 g) received 6 sessions of trauma-focused cognitive behavior therapy (CBT). Outcomes were compared with those of a previously published RCT, which tested an individual therapy based on the same model in a group of 62 mothers. Results were also compared across in-person and telehealth treatment. ResultsFrom baseline to follow up, the individual intervention showed greater improvement in trauma symptoms assessed with the Davidson Trauma Scale (d = 0.48, p = 0.016), although both conditions showed clinically significant improvement. Similar patterns were found for maternal depression and anxiety. In-person treatment was found to be superior to telehealth treatment administered during the COVID-19 pandemic, although the difference was not significant. ConclusionsGroup-based trauma focused CBT is an effective treatment modality for parents of premature infants with symptoms of psychological distress but not as effective as individual therapy using the same treatment model.

The integration of yoga breathing techniques in cognitive behavioral therapy for post-traumatic stress disorder: A pragmatic randomized controlled trial.

In trauma-focused Cognitive Behavioral Therapy (TF-CBT), stabilization techniques are used before confrontation ones to increase stress/affect tolerance and thus effectiveness of CBT. This study investigated the effects of pranayama, meditative yoga breathing and breath holding techniques, as a complimentary stabilization technique in patients with post-traumatic stress disorder (PTSD). Seventy-four PTSD-patients (84% female, 44.2 ± 13 years) were randomized to receive either pranayama at the beginning of each TF-CBT session or TF-CBT alone. The primary outcome was self-reported PTSD severity after 10 sessions of TF-CBT. Secondary outcomes included quality of life, social participation, anxiety, depression, distress tolerance, emotion regulation, body awareness, breath-holding duration, acute emotional reaction to stress, and adverse events (AEs). Intention-to-treat (ITT) and exploratory per-protocol (PP) analyses of covariance with 95% confidence intervals (CI) were performed. ITT analyses revealed no significant differences on primary or secondary outcomes, except for breath-holding duration in favor of pranayama-assisted TF-CBT (20.81 s, 95%CI = 13.05|28.60). PP analyses of 31 patients without AEs during pranayama revealed significantly lower PTSD severity (-5.41, 95%CI = -10.17|-0.64) and higher mental quality of life (4.89, 95%CI = 1.38|8.41) than controls. In contrast, patients with AEs during pranayama breath holding reported significantly higher PTSD severity (12.39, 95%CI = 5.08|19.71) than controls. Concurrent somatoform disorders were found to be a significant moderator of change in PTSD severity (p = 0.029). In PTSD patients without concurrent somatoform disorders, the integration of pranayama into TF-CBT might reduce post-traumatic symptoms and increase mental quality of life more efficiently than TF-CBT alone. The results remain preliminary until they can be replicated by ITT analyses. ClinicalTrials.gov, identifier NCT03748121.

Neural correlates of irritability symptom relief in adolescents pre- and post-trauma-focused cognitive behavioral therapy: A pilot study on reward processing

Despite that Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is a first-line, evidence-based treatment for youths experiencing trauma-related symptoms, treatment responses vary and it remains unclear for whom and how this treatment works. In this context, we examined pre-treatment neural reward processing and pre- vs. post-treatment changes in neural reward processing, in relation to irritability – a transdiagnostic and dimensional feature present in multiple trauma-related syndromes, following TF-CBT. Adolescents (N = 22) with childhood trauma history completed a child-friendly monetary incentive delay task during fMRI acquisition, prior to and after the treatment, and irritability symptoms were assessed at five time points over the course of the treatment. Individual irritability slopes (i.e., irritability change rate) and intercepts (i.e., initial irritability level), generated by linear growth curve modeling, were integrated with fMRI data. Repeated ANCOVAs demonstrated that both pre-treatment neural response to reward and pre- vs. post-treatment changes in neural reward processing correlated with irritability symptom relief, such that opposite baseline neural reward processing profiles and differential changing patterns were observed in individuals showing irritability symptom relief vs. not. Together, our findings provide proof of concept that integrating brain information with clinical information has the potential to identify predictors and mechanisms of symptom relief.

Examining the Feasibility of Telehealth Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) with Young People in Foster Care.

Purpose: Despite the high rate of trauma exposure among young people with child welfare involvement, various systematic and patient barriers exist that inhibit utilization of evidence-based trauma treatments. One strategy for alleviating barriers to such treatments is using telehealth. A few studies have found that the clinical outcomes of telehealth TF-CBT are comparable to those found from clinic-based, in-person treatment administration. Studies have yet to examine the feasibility of telehealth TF-CBT with young people in care. The current study sought to address this gap by examining outcomes for patients who received telehealth TF-CBT, along with factors that may have impacted successful completion, at an integrated primary care clinic exclusively serving young people in care. Methods: Patient data were collected retrospectively from the electronic health records of 46 patients who received telehealth TF-CBT between March 2020 and April 2021, and feedback was sought via focus group from 7 of the clinic's mental health providers. A paired-sample t-test was conducted to evaluate the impact of the intervention for the 14 patients who completed treatment. Results: Responses from the Child and Adolescent Trauma Screen showed a significant decrease in posttraumatic stress symptoms when comparing pre-treatment scores (M = 25.64, SD = 7.85) to post-treatment scores (13.57, SD = 5.30), t(13) = 7.50, p < .001. The mean decrease in scores was 12.07 with a 95% confidence interval ranging from 8.60 to 15.55. Themes emerging from the focus group centered on home environment, caregiver participation, and systemic topics. Conclusions: Findings suggest that telehealth TF-CBT with young people in care is feasible but relatively low completion rates suggest that barriers to treatment completion remain.

Unified Protocol vs Trauma-Focused Cognitive Behavioral Therapy Among Adolescents With PTSD

Harmful consequences of COVID-19, such as prolonged quarantine, lack of social contact, and especially loss of parents or friends, can negatively impact children and adolescents’ mental health in diverse ways, including engendering posttraumatic stress symptoms. Our study is the first to compare the transdiagnostic Unified Protocol for the Treatment of Emotional Disorders in Adolescents (UP-A; Ehrenreich et al., 2009; Ehrenreich-May et al., 2017) with Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in terms of outcomes related to PTSD symptoms (COVID-19-related vs. COVID-19 unrelated PTSD) and comorbid symptoms (i.e., anxiety, depression) and other measures (i.e., emotion regulation, self-injury, anger). Individuals diagnosed with PTSD were randomly assigned to the UP-A (n = 46) or TF-CBT group (n = 47), administered the SCID-5 and a battery of measures and followed up posttreatment and then after 3, 6, and 9 months. Ninety-three adolescents with PTSD were enrolled, 45% boys and 61% COVID-19-related PTSD. We adopted an intention-to-treat approach. At the initial post-intervention assessment, except for emotion regulation and unexpressed angry feelings, in which UP-A participants reported greater reductions, no significant differences in other variables were secured between the UP-A and TF-CBT. However, at follow-up assessments, the UP-A evidenced significantly better outcomes than TF-CBT. We found support for the UP-A compared with TF-CBT in treating adolescents with PTSD, regardless of COVID-19-related PTSD status, in maintaining treatment effectiveness over time.

Developing a trauma focused cognitive behavioral therapy application for adolescents with problematic sexual behaviors: A conceptual framework

Sexual abuse (SA) perpetration is a significant public health problem; SA perpetration is most likely to emerge during adolescence and youth ages 13 to 17 account for a significant portion of all child sexual abuse. While research shows that these youth have high rates of adversity, once they have engaged in problem sexual behavior (PSB), their own trauma histories are often ignored with treatment primarily focused on reducing risk for reoffending. Although sexual re-offense rates among adolescents with PSB are very low, the rates of non-sexual recidivism are considerably higher; with almost half of known youth have reoffended non-sexually, requiring development, implementation, and testing of therapeutic interventions responsive to the indicated risks and unmet needs of adolescents who have engaged in a range of problematic sexual behaviors (PSB-A) and their families. Yet, there are no empirically supported interventions designed specifically to address PSB-A with trauma histories. This article introduces how Trauma-Focused Cognitive Behavioral Therapy can be applied to PSB-A and provides implications for practice and future research.

Stability of Treatment Effects and Caregiver-Reported Outcomes: A Meta-Analysis of Trauma-Focused Cognitive Behavioral Therapy for Children and Adolescents.

The efficacy of trauma-focused treatments for children and adolescents is well researched. However, less is known about the long-term and caregiver-reported effects. Searched databases were PsychInfo, MEDLINE, Cochrane Library, PTSDPubs, PubMed, Web of Science, and OpenGrey. Treatment effects of trauma-focused cognitive behavioral therapy (TF-CBT) were computed at 12-month follow-up with posttraumatic stress symptoms (PTSS) as primary outcome and symptoms of depression, anxiety, and grief as secondary outcomes. Concordance between participant and caregiver ratings were investigated. TF-CBT showed large improvements across all outcomes from pre-treatment to 12-month follow-up (PTSS: g = 1.71, CI 1.27-2.15) and favorable results compared to active treatments and treatment as usual at 12-month follow-up (PTSS: g = .35, CI .13-.56). More pronounced effects were found in group settings. No significant differences were detected between participant and caregiver ratings with high reliability across almost all outcomes and assessment points. TF-CBT is a reliable treatment for pediatric PTSS and secondary symptoms with stable results at 12-month follow-up.

A Comparison of the Readiness of Youth Service Agencies to Implement a Technology-Based Toolkit to Support Treatment Delivery.

Implementation initiatives and technology-based resources aim to address barriers to Evidence-Based Practice (EBP) use by creating generalizable techniques that can be used for a variety of youth-serving agencies. However, research has not carefully examined unique differences between agency types or individual programs in readiness to use such technologies and implementation strategies. The current study explored differences between community mental health clinics and child advocacy centers on organizational cultural factors (e.g., ability to change and commitment for change) to implement a novel technology-based toolkit to support delivery of Trauma Focused Cognitive Behavioral Therapy (TF-CBT). Results indicated that TF-CBT providers from child advocacy centers reported greater commitment to change and more support to use the technology-based system than those from community mental health centers. Findings suggest that implementation initiatives should address the needs of individual agencies and service settings and adaptations should be explored to best meet the needs of these settings.

Effectiveness of abbreviated trauma-focused cognitive behavioural therapy for South African adolescents: a randomized controlled trial

ABSTRACT Background: In low- and middle- income countries (LMICs) trauma exposure among youth is high, but mental health services are critically under-resourced. In such contexts, abbreviated trauma treatments are needed. Objective: To evaluate the efficacy of an abbreviated eight-session version of Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) for improving posttraumatic stress disorder (PTSD) and depression symptoms in a sample of South African adolescents. Method: 75 trauma-exposed adolescents (21 males, 54 females; mean age = 14.92, range = 11–19) with posttraumatic stress disorder (PTSD) symptoms were randomly assigned to eight sessions of TF-CBT or to usual services. At baseline, post-treatment and three-month follow-up, participants completed the Child PTSD Symptom Scale for DSM 5 (CPSS-5) and the Beck Depression Inventory II (BDI-II). The trial is registered on the Pan African Trial Registry (PACTR202011506380839).6. Results: 95% of TF-CBT participants completed treatment while only 47% of TAU participants accessed treatment. Intention-to-treat analyses found that the TF-CBT group had a significantly greater reduction in CPSS-5 PTSD symptom severity at post-treatment (Cohen’s d = 0. 60, p < .01) and three-month follow-up (Cohen’s d = 0.62, p < . 01), and a greater reduction in the proportion of participants meeting the CPSS-5 clinical cut-off for PTSD at both time points (p = .02 and p = .03, respectively). There was also a significantly greater reduction in depression symptom severity in the TF-CBT group at post-treatment (Cohen’s d = 0.51, p = .03) and three-month follow-up (Cohen’s d = 0.41, p = .05), and a greater reduction in the proportion of TF-CBT participants meeting the BDI clinical cut-off for depression at both time points (p = .02 and p = .03, respectively). Conclusion: The findings provide preliminary evidence of the efficacy of an abbreviated eight-session version of TF-CBT for reducing PTSD and depression symptoms in a LMIC sample of adolescents with multiple trauma exposure.

Efficacy of psychological interventions for post-traumatic stress disorder in children and adolescents exposed to single versus multiple traumas: meta-analysis of randomised controlled trials.

Previous meta-analyses of psychotherapies for children and adolescents with post-traumatic stress disorder (PTSD) did not investigate whether treatment efficacy is diminished when patients report multiple (versus single) traumas. To examine whether efficacy of psychological interventions for paediatric PTSD is diminished when patients report multiple (versus single) traumas. We systematically searched PsycInfo, MEDLINE, Web of Science and PTSDpubs on 21 April 2022 and included randomised controlled trials (RCTs) meeting the following criteria: (a) random allocation; (b) all participants presented with partial or full PTSD; (c) PTSD is the primary treatment focus; (d) sample mean age <19 years; (e) sample size n ≥ 20. Trauma frequency was analysed as a dichotomous (single versus ≥2 traumas) and continuous (mean number of exposures) potential moderator of efficacy. Of the 57 eligible RCTs (n = 4295), 51 RCTs were included in quantitative analyses. Relative to passive control conditions, interventions were found effective for single-trauma-related PTSD (Hedges' g = 1.09; 95% CI 0.70-1.48; k = 8 trials) and multiple-trauma-related PTSD (g = 1.11; 95% CI 0.74-1.47; k = 12). Psychotherapies were also more effective than active control conditions in reducing multiple-trauma-related PTSD. Comparison with active control conditions regarding single-event PTSD was not possible owing to scarcity (k = 1) of available trials. Efficacy did not differ with trauma exposure frequency irrespective of its operationalisation and subgroup analyses (e.g. trauma-focused cognitive-behavioural therapy only). The current evidence base suggests that psychological interventions for paediatric PTSD can effectively treat PTSD in populations reporting single and multiple traumas. Future trials for PTSD following single-event trauma need to involve active control conditions.

A 28-Day, Randomized, Controlled, Single-Blind, Phase 2 Study in Treatment-Resistant Major Depressive Disorder (TRD) Patients Receiving Intranasal Esketamine Comparing Addition of Almond Therapy TM with Treatment-as-Usual (TAU)

IntroductionTreatment Resistant Depression (TRD) occurs in up to 30% of patients with Major Depressive Disorder (MDD). New treatments are clearly needed and there is a burgeoning interest in novel agents including ketamine. While ketamine in various formulations has been demonstrated to have a robust antidepressant effect there is a lack of evidence-based psychotherapies specifically designed for combination use.ObjectivesWe hypothesize that the combination of “Almond TherapyTM” with intranasal ketamine will result in a statistically significantly better outcome as demonstrated by a greater reduction in MADRS scores and/or response rates and/or remission rates in TRD patients compared with those who receive esketamine plus TAU. Secondary outcome measures include PHQ-9, GAD-7, PCL-5, Asssessment of Quality of Life - 8D (AQOL-8D), and Rosenberg Self-Esteem Scale.MethodsWe have developed a research protocol combining a unique and specifically-designed, multi-modal psychotherapy program, “Almond TherapyTM”, with intranasal esketamine in a randomized, controlled, single-blind 28-day study. The therapy utilizes an individualized, evidence-informed approach for each participant consisting of a number of modules selected using a shared decision-making process determined at the first study visit. This uniquely tailored approach ensures that the chosen modules are personally meaningful to the participant, and thus, promotes therapeutic adherence. The proprietary therapy combines elements of cognitive behavioral therapy (CBT), trauma focused-CBT, Dialectical Behavioral Therapy (DBT), and mindfulness, together with biofeedback. In addition to in-clinic sessions, participants also receive standardized remote therapy sessions by trained therapists.ResultsPatient recruitment and enrolment has begun. Interim results are anticipated.ConclusionsThis study is the first examination of the potential additional clinical benefit of adding a specific therapy program to existing intranasal esketamine treatment. If demonstrated to be of clinical benefit then further studies may potentially provide comparison to other therapy programs and in conjunction with other agents.Disclosure of InterestP. Chue Shareolder of: Zylorion, P. Silverstone Shareolder of: Zylorion, Employee of: Zylorion, T. Hillier Shareolder of: Zylorion, Employee of: Zylorion, S. Rizvi: None Declared, S. Phillips Shareolder of: Zylorion, Employee of: Zylorion, L.-A. Langkaas Employee of: Zylorion, K. Davidson Employee of: Zylorion, M. Brown: None Declared, J. Chue: None Declared

Effectiveness of a school-based, lay counselor-delivered cognitive behavioral therapy for Chinese children with posttraumatic stress symptoms: a randomized controlled trial

Improving children's access to mental health services need more innovative solutions, especially in low- and middle-income countries. School-based psychosocial interventions delivered by lay counselors may be an efficient way to improve children's access to mental health services. But few studies were conducted to examine the effectiveness of these interventions. Therefore, this study is to evaluate the effectiveness of trauma-focused cognitive behavioral therapy (TF-CBT) in a group format delivered by lay counselors to children with trauma-related symptoms in China. A total of 234 children (aged 9-12 years) with full or subthreshold posttraumatic stress disorder (PTSD) were randomly assigned to group-based TF-CBT or treatment as usual (TAU). In the intervention group, 118 children received 10-12 sessions of group-based TF-CBT delivered by lay counselors for 9 consecutive weeks. In the TAU group, 116 children received the usual school services provided by psychology teachers. The primary outcome was the reduction in PTSD severity, which was assessed with the UCLA PTSD reaction index for DSM-5 (PTSD-RI-5). The secondary outcomes included the reduction in PTSD severity and the remission of PTSD, both of which were measured with the PTSD checklist-5 (PCL-5). Secondary outcomes also included the reduction in depression severity and the reduction in generalized anxiety severity. Blinded assessments were collected at baseline, posttreatment (primary endpoint), and 3-month follow-up. This trial is registered with Chinese Clinical Trial Registry, ChiCTR1900027131. At posttreatment, the intervention group scored significantly lower than the TAU group on PTSD-RI-5 PTSD (30.98 vs. 39.22; adjusted mean difference [AMD],-7.35; 95% CI,-11.66 to-3.04), PCL-5 PTSD (28.78 vs. 38.04; AMD,-8.49; 95% CI,-13.23 to-3.75), depression (5.52 vs. 7.96; AMD,-1.63; 95% CI,-2.50 to-0.76), and generalized anxiety (7.23 vs. 8.64; AMD,-1.21; 95% CI,-2.20 to-0.23). The remission of PCL-5 PTSD was also significantly higher in the intervention group (42.86% vs. 13.54%, χ 2 =13.10, P<0.001). These two groups showed a similar level of symptoms at the 3-month follow-up. The group-based TF-CBT can significantly alleviate PTSD, depression, and generalized anxiety right after treatment in Chinese children who suffer from different types of trauma. But the long-term effects of this intervention need to be further tested. This intervention can be delivered by trained lay counselors in low- and middle-income countries. None.

Mindfulness-Oriented Recovery Enhancement: An Evidence-Based Social Work Intervention for Addiction, Stress, and Chronic Pain.

The purpose of this commentary is to update social workers about the evolution of Mindfulness-Oriented Recovery Enhancement (MORE) since the publication of the book Mindfulness-Oriented Recovery Enhancement for Addiction, Stress, and Pain (Garland, 2013, reviewed in Martin, 2022) and to provide a succinct overview of MORE’s clinical outcomes and mechanisms. MORE is an evidence-based social work intervention that unites mindfulness training, cognitive–behavioral therapy (CBT), and positive psychology into an integrative treatment for addiction, stress, and chronic pain. Across weekly MORE sessions, participants learn mindfulness, reappraisal, and savoring techniques to alleviate symptoms, enhance well-being, and strengthen their recovery. MORE draws on principles from social–behavioral learning theory to enhance motivation to practice, maximize therapeutic expectancy, and positively reinforce success experiences to increase participant engagement. Since 2013, MORE has been tested in 11 clinical trials, demonstrating efficacy for clients struggling with addiction and related issues (e.g., psychiatric disorders, chronic pain). The first Stage 1 randomized controlled trial (RCT) of MORE was conducted in a sample of people with alcohol use disorder (many of whom had co-occurring cocaine use disorder) residing in a long-term therapeutic community. This pilot (N = 53) provided an initial indication of MORE’s potential treatment value, demonstrating effects on addiction risk mechanisms including alcohol attentional bias and autonomic recovery from alcohol cue exposure—indicators of the extent to which a patient was “triggered” by addiction cues (Garland et al., 2010). Subsequently, my colleagues and I launched a five-year Stage 3 RCT (N = 180) of MORE at the same therapeutic community in a sample of formerly homeless men with co-occurring substance use disorders, trauma, and psychiatric disorders. MORE outperformed both trauma-focused CBT (a program based on Seeking Safety) and usual care in reducing drug craving and PTSD symptoms (Garland et al., 2016). For these first two trials of MORE, the treatment was targeted for clients in the “action” and “maintenance” stages of change (Prochaska et al., 1992).

Understanding Lay Counselor Perspectives on Mobile Phone Supervision in Kenya: Qualitative Study.

Task shifting is an effective model for increasing access to mental health treatment via lay counselors with less specialized training that deliver care under supervision. Mobile phones may present a low-technology opportunity to replace or decrease reliance on in-person supervision in task shifting, but important technical and contextual limitations must be examined and considered. Guided by human-centered design methods, we aimed to understand how mobile phones are currently used when supervising lay counselors, determine the acceptability and feasibility of mobile phone supervision, and generate solutions to improve mobile phone supervision. Participants were recruited from a large hybrid effectiveness implementation study in western Kenya wherein teachers and community health volunteers were trained to provide trauma-focused cognitive behavioral therapy. Lay counselors (n=24) and supervisors (n=3) participated in semistructured interviews in the language of the participants' choosing (ie, English or Kiswahili). Lay counselor participants were stratified by supervisor-rated frequency of mobile phone use such that interviews included high-frequency, average-frequency, and low-frequency phone users in equal parts. Supervisors rated lay counselors on frequency of phone contact (ie, calls and SMS text messages) relative to their peers. The interviews were transcribed, translated when needed, and analyzed using thematic analysis. Participants described a range of mobile phone uses, including providing clinical updates, scheduling and coordinating supervision and clinical groups, and supporting research procedures. Participants liked how mobile phones decreased burden, facilitated access to clinical and personal support, and enabled greater independence of lay counselors. Participants disliked how mobile phones limited information transmission and relationship building between supervisors and lay counselors. Mobile phone supervision was facilitated by access to working smartphones, ease and convenience of mobile phone supervision, mobile phone literacy, and positive supervisor-counselor relationships. Limited resources, technical difficulties, communication challenges, and limitations on which activities can be effectively performed via mobile phone were barriers to mobile phone supervision. Lay counselors and supervisors generated 27 distinct solutions to increase the acceptability and feasibility of mobile phone supervision. Strategies ranged in terms of the resources required and included providing phones and airtime to support supervision, identifying quiet and private places to hold mobile phone supervision, and delineating processes for requesting in-person support. Lay counselors and supervisors use mobile phones in a variety of ways; however, there are distinct challenges to their use that must be addressed to optimize acceptability, feasibility, and usability. Researchers should consider limitations to implementing digital health tools and design solutions alongside end users to optimize the use of these tools. RR2-10.1186/s43058-020-00102-9.