In short, what is the study about?
This study focused on a few unanswered questions about what therapy is preferred by mental health professionals for patients who are suffering from the after-effects of trauma, and questions about when patients appear to experience negative reactions to treatment. The study was specifically designed to examine 1) if clinicians were more likely to favor using exposure therapy or phase-oriented therapy if they judged that a patient’s trauma symptoms included dissociation, and 2) whether clinicians had experienced patients worsening following exposure therapy and following phase-oriented therapy.
Exposure therapy has patients moving quickly to confront their feelings, memories, thoughts and physiological responses associated with the traumatic event they experienced. In some forms of exposure therapy, patients also confront cues in the external world associated with the trauma, such as the location it happened in, objects that were present, or the smells or sounds experienced at the time. Phase-oriented therapy withholds exposure work until after a period of stabilization has occurred, where the patient is more able to tolerate the reminders and representations of their trauma history without being retraumatized and drawing on maladaptive coping strategies (e.g., alcohol use, self-harm, dissociation).
The study assessed 263 mental health professionals from around the world in a survey of their treatment experience and preferences for traumatized patients. The survey consisted of two case study descriptions and a series of questions relating to the case studies, as well as their experience working with traumatized patients. One of the case studies presented a patient where dissociative symptoms were prominent and severe, and in the other case study, dissociative symptoms were not prominent.
What would be the most important take-home messages from the study?
- Clinicians who diagnosed the patients in the case studies as having considerable dissociative symptoms are more likely to opt for a phase-oriented therapy approach.
- Negative reactions to treatment are not uncommon in those presenting with trauma disorders but seem to be reduced when a phase-oriented approach is adopted.
- More experienced therapists tended to prefer phase-oriented therapy over exposure therapy for trauma patients with considerable dissociative symptoms.
- More experienced therapists seemed to report having seen more negative reactions to trauma treatment, perhaps because they have treated more patients and get referred more challenging presentations.
How are these findings important in practice?
- Clinicians should observe patients astutely for dissociative symptoms and if such symptoms are present, should consider spending time with the patient on stabilizing measures, before engaging in exposure work.
- Clinicians should ensure that all traumatized patients have an adequate level of stabilization before engaging in exposure work, and should always remain vigilant for detrimental effects of treatment, even when using phase-oriented therapy.
- Traumatized patients should be aware that alternative types of therapy are available, should they experience negative reactions to the therapy they received.
What other studies can be recommended to further an understanding/application of the findings?
- Cloitre, M., Courtois, C. A., Ford, J. D., Green, B. L., Alexander, P., Briere, J., . . . Van Der Hart, O. (2012). The ISTSS expert consensus treatment guidelines for complex PTSD in adults. Retrieved from http://bit.ly/2eTzyYa
- De Jongh, A., Resick, P. A., Zoellner, L. A., Van Minnen, A., Lee, C. W., Monson, C. M., & Bicanic, I. A. E. (2016). Critical analysis of the current treatment guidelines for complex PTSD in adults. Depression and Anxiety, 33, 359–369. doi:10.1002/da.22469
- Jepsen, E. K. K., Langeland, W., & Heir, T. (2013). Impact of dissociation and interpersonal functioning on inpatient treatment for early sexually abused adults. European Journal of Psychotraumatology, 4, 22825. doi:10.3402/ejpt.v4i0.22825
Link to the primary paper:
Dorahy, M. J., Lewis-Fernández, R., Krüger, C., Brand, B. L., Şar, V., Ewing, J., Martínez-Taboas, A., Stavropoulos, P., & Middleton, W. (2016). The role of clinical experience, diagnosis, and theoretical orientation in the treatment of posttraumatic and dissociative disorders: A vignette and survey investigation. Journal of Trauma and Dissociation, 27, 1-17. doi:10.1080/15299732.2016.1225626
Prepared by Martin Dorahy, Christa Krüger & Alfonso Martínez-Taboas