Journal of Traumatic Stress February 2014, 27, 1–8

The Evidence for Present-Centered Therapy as a Treatment for Posttraumatic Stress Disorder Nickolas D. Frost,1 Kevin M. Laska,1,2 and Bruce E. Wampold1,3 1

Department of Counseling Psychology, University of Wisconsin, Madison, Wisconsin, USA 2 Bedford VA Medical Center, Bedford, Massachusetts, USA 3 Research Institute, Modum Bad Psychiatric Center, Vikersund, Norway

To examine the evidence for present-centered therapy (PCT) as a treatment for posttraumatic stress disorder (PTSD), 5 randomized clinical trials that compared PCT to an existing evidence-based treatment for PTSD were reviewed. A meta-analysis was used to estimate betweentreatment differences on targeted measures, secondary measures, and dropout. PCT was found to be as efficacious as the comparison evidence-based treatment in 3 of the 5 trials, and in the 2 cases where a no-treatment condition was included, PCT was superior, with large effect sizes for targeted variables (d = 0.88, 0.74, and 1.27). When results were aggregated using meta-analysis, effects for PCT versus an evidence-based treatment for both targeted and secondary measures were small and nonsignificant (d = 0.13 and d = 0.09, respectively). As well, the dropout rate for PCT was significantly less than for the comparison evidence-based treatments (14.3% and 31.3%, respectively). It appears that PCT is an efficacious and acceptable treatment for PTSD.

Posttraumatic stress disorder (PTSD) is one of the most prevalent and costly psychological disorders in the United States, affecting a wide range of individuals from diverse backgrounds. Furthermore, prevalence rates of PTSD exceed other anxiety disorders with the exception of specific phobias and social phobia (Kessler, Chiu, Demler, & Walters, 2005). To improve the quality of mental health service delivery for individuals with PTSD, the field has begun to identify various evidence-based treatments. The practice guidelines put forth by the International Society of Traumatic Stress Studies (ISTSS) stipulate a multilevel system for PTSD treatments. This system classifies evidence in support of a treatment into various levels, the highest of which (noted as Level A) includes evidence from randomized clinical trials for individuals with PTSD (Foa, Keane, Friedman, & Cohen, 2009, p. 16). Several treatments meet the criteria for Level A, including (a) prolonged exposure therapy (PE), (b) cognitive processing therapy (CPT), (c) stress inoculation therapy, and (d) trauma-focused cognitive–behavior therapy (Foa et al., 2005; Monson et al., 2006; Resick, Nishith, Weaver, Astin, & Feuer, 2002). In addition, PE and CPT are currently being disseminated in U.S. Department of Veterans

Affairs (VA) hospitals nationwide in an attempt to improve the quality of mental health service delivery for veterans (Karlin et al., 2010; McHugh & Barlow, 2010). Despite the progress that has been made toward treating PTSD by identifying evidence-based treatments, there are some caveats. One particularly troublesome issue is that despite the proven efficacy of various treatments, many patients drop out from these treatments, as demonstrated in clinical trials (e.g., McDonagh et al., 2005; see Imel, Laska, Jakupcak, & Simpson, 2013, for a research synthesis of dropout) and in practice (Garcia, Kelley, Rentz, & Lee, 2011). If patients are not able to tolerate a particular treatment, there is a need for alternative efficacious treatments. A particularly promising treatment for PTSD is present-centered therapy (PCT) and the purpose of the present study is to review clinical trials that have compared PCT to established evidence-based treatments. It appears that Schnurr et al. (2003) was the first in the trauma field to use the term “present-centered” when describing an approach to therapy that was used as a control for the nonspecific benefits of psychotherapy. Although the supportive therapy used by Foa, Rothbaum, Riggs, and Murdock (1991) focused on the present, to rule out exposure, the approach used by Schnurr et al. differed because there was a strong theoretical rationale for their present-centered approach. Since Schnurr et al., PCT implemented in clinical trials has contained therapeutic ingredients based on psychological principles, has been guided by a treatment manual, and has involved therapists trained to deliver the treatment faithfully (e.g. Classen et al., 2011; McDonagh

Correspondence concerning this article should be addressed to Bruce Wampold, Department of Counseling Psychology, 335 Education Building, 1000 Bascom Mall, University of Wisconsin, Madison WI 53706. E-mail: [email protected] C 2014 International Society for Traumatic Stress Studies. View Copyright  this article online at wileyonlinelibrary.com DOI: 10.1002/jts.21881

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et al., 2005; Schnurr et al., 2003; Schnurr, Shea, Friedman, & Engel, 2007; Sur´ıs, Link-Malcolm, Chard, Ahn, & North, 2013). The primary mechanisms of change from a present-centered perspective are grounded in altering present maladaptive relational patterns/behaviors, providing psychoeducation regarding the impact of trauma on the client’s current life, and teaching the use of problem-solving strategies (Classen et al., 2011; McDonagh et al., 2005; Schnurr et al., 2003). This approach to treating PTSD represents a paradigmatic contrast with other approaches that are trauma focused (Bisson et al., 2007a, 2007b; Ehlers et al., 2010). Here we review five trials that have compared PCT to an evidence-based treatment for PTSD. In this chronological review, we summarize the results of the comparisons of PCT to an evidence-based treatment, describe the effects of PCT versus no treatment controls for targeted variables when such controls were included in the trial, and estimate the pretreatment to posttreatment change on the primary PTSD measure for PCT and the evidence-based treatment, focusing on the intent-to-treat samples in all instances. We then conduct a meta-analysis of the five trials.

Review of Clinical Trials Trial 1 In 2003, Schnurr et al. compared present-centered group therapy (PCGT) to trauma-focused group therapy (TFGT) for the treatment of PTSD in Vietnam veterans. Both treatment protocols were structured with treatment manuals (see Schnurr, Friedman, Lavori, & Hsieh, 2001; Foy, Glynn, Riney, & Gusman, 1997), were delivered in a 30-week group format with five booster sessions, contained similar doses of treatment, and utilized similarly trained clinicians. The clinicians in each condition were provided supervision and treatment adherence was assessed. The PCGT focused on the group processes, psychoeducation about PTSD symptoms and features, as well as the relation between PTSD symptoms and difficulties in relationships, the identification of problems, and the development of plans to deal with current problems. TFGT, the evidenced-based treatment to which PCGT was compared, extensively involved exposure, although it was “developed specifically for patients who might not otherwise tolerate or comply with individual exposure therapy” (p. 482). In this trial, 360 Vietnam-era veterans from 10 Department of Veterans Affairs medical centers diagnosed with combat– related PTSD were randomly assigned to the two treatments. The targeted outcome variables were related to PTSD severity; secondary outcome variables contained measures of other symptoms, functional status, quality of life, physical health, and service utilization. The primary analysis involved 325 patients who had at least one assessment at either 7 months (at the end of the active

treatment phase) or 12 months (at the end of booster sessions), whether or not they completed treatment (i.e., the intent-totreat sample). Both treatments were effective, in that change on the Clinician-Administered PTSD Scale (CAPS), a measure of PTSD severity and the primary measure, showed significant change. Table 1 includes the baseline to 7-month time point effect sizes (see Becker, 1988, Equation 2, p. 260). At 7 months and 12 months, respectively, 37.5% and 43.2% of present-focused patients and 38.8% and 44.7% of traumafocused patients, respectively, experienced more than a 10-point change in the CAPS, although the gains in this trial for the two treatment conditions were smaller than they were for the other trials. Although patients improved in both conditions, no statistically significant differences between the two treatments were found on any outcome variable at either of the time points. The effect sizes (positive effects reflect evidence-based treatment superiority and negative effects represent PCT superiority) as well as associated probability levels for testing whether the effect is significantly different from zero are presented in Table 2 for the earlier time point. Despite the intention to design an exposure treatment that was tolerable for patients, significantly more patients dropped out of TFGT than PCGT in the active treatment phase (22.8% vs. 8.6%; odds ratio [OR] of completing PCGT versus completing TFGT = 3.15, p < .001; see Table 2 where an OR > 1.00 reflects PCT superiority). On the other hand, for those who had an adequate dose of treatment (at least 24 active treatment sessions), TFGT was superior to PCGT on only two measures of PTSD severity (avoidance and numbing). The Schnurr et al. (2003) trial, which had more than adequate power, found few if any differences between PCT and an evidence-based treatment for PTSD. Additionally, patients seemed to tolerate the present-focused treatment to a greater extent than the exposure based treatment as evidenced by fewer dropouts in the present-focused treatment. Trial 2 The second trial to examine the efficacy of PCT was conducted by McDonagh et al. in 2005. Patients in this trial were 74 women who were victims of childhood sexual abuse and met diagnostic criteria for PTSD. The patients were randomly assigned to one of three conditions: PCT, cognitive–behavioral treatment (CBT), and a waitlist control group. The targeted measure was PTSD severity, as measured by the CAPS. Secondary measures included measures of depression, anxiety, anger expression, quality of life, and PTSD diagnosis (percentage who met criteria). Analyses were conducted at termination and 3- and 6-month follow-up. The particular variant of PCT used in this study, although designed to exclude aspects of CBT such as exposure, breathing retraining, and cognitive restructuring, was an active treatment based on a problem solving model focused on present difficulties and developing coping strategies. CBT in this trial was a modification of Foa et al.’s (1999) protocol and included

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

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Present-Centered Therapy

Table 1 Baseline and Posttreatment Means and Standard Deviations for PTSD Symptoms and Effect Size for PCT and Comparison Treatment in Five Studies Baseline Study Schnurr et al., 2003 PCGT TFGT McDonagh et al., 2006 PCT CBT Schnurr et al., 2007 PCT PE Classen et al., 2011b PFGT TFGT Sur´ıs et al., 2013 PCT CPT

Variable

Posttreatment

N

M

SD

M

SD

Pre- to posteffecta

163 162

82.01 80.41

18.38 18.46

76.03 74.00

16.85 16.80

0.32 0.35

22 29

67.7 69.9

14.60 16.80

47.2 53.1

22.4 28.8

1.40 1.00

143 141

77.9 77.6

16.47 18.18

60.1 52.9

28.68 30.90

1.08 1.36

55 56

47.1 46.1

12.86 14.92

36.5 36.7

14.28 11.66

0.82 0.63

34 52

83.8 85.1

19.18 19.40

68.64 64.97

21.05 23.58

0.79 1.03

CAPS

CAPS

CAPS

PTSD severity

CAPS

Note. CAPS = Clinician-Administered PTSD Scale; PCT = Present-Centered Therapy; CBT = Cognitive Behavioral Therapy; PCGT = Present-Centered Group Therapy; TFGT = Trauma-Focused Group Therapy; PE = Prolonged Exposure; CPT = Cognitive Processing Therapy. a Pretreatment to posttreatment effects were calculated by dividing the pre- to postdifference by the standard deviation of the baseline (see Becker, 1988, Equation 2). b Classen reported slopes rather than means for outcome variables. The effects reported here were based on means and standard deviations of for PTSD Total Severity at baseline and 6-month follow-up provided by C. Classen (personal communication, May 2, 2013).

prolonged exposure, in vivo exposure, breathing retraining, and cognitive restructuring. In each treatment, patients received 14 individual sessions. Both CBT and PCT were found to be superior to the notreatment control group. The effect for the CAPS for PCT, the targeted measure, versus the waitlist-control group was large (d = 0.88) and statistically significant (p < .001). The effects of PCT and CBT on the CAPS from pretreatment to posttreatment are found in Table 1, where it is apparent that both treatments resulted in patient improvement. For the intent-to-treat sample, there were no statistically significant differences between CBT and PCT at termination and follow-up, including PTSD symptom severity (see Table 2). Patients found PCT to be more tolerable than CBT as evidenced by significant differences in the dropout rate (41.4% for CBT and 8.6% for PCT, OR = 7.06, p = .019). For patients who were able to tolerate CBT (i.e., in the completer sample), the proportion of patients meeting diagnostic criteria for PTSD was lower at follow-up (but not at termination) than those patients who completed PCT, although there were no significant differences between the treatments for these patients in PTSD symptom severity, as measured by the CAPS, or for any of the other measures, at either termination or follow-up. In this trial, PCT was as efficacious as and more tolerable than CBT, an evidence-based treatment for PTSD. Although the sample size was relatively small (n = 22 in PCT and n = 29 in CBT), the effects were either very small or favored PCT in

the intent-to-treat sample and consequently large sample size would not have likely been able to produce evidence favoring CBT. Trial 3 Although the first two trials presented found that PCT appeared to be as effective as an evidence-based comparison, Schnurr et al. (2007) found that PE was superior to PCT on targeted variables. In this study, female veterans or active duty personnel with PTSD were randomly assigned to PE (n = 141) or PCT (n = 143), delivered in 10 weekly sessions. The PE treatment included “education about common reactions to trauma; breathing retraining; prolonged (repeated) recounting (imaginal exposure) of trauma memories during sessions; homework (listening to a recording of the recounting made during the therapy session and repeated in vivo exposure to safe situations the patient avoids because of trauma-related fear); and discussion of thoughts and feelings related to exposure exercises” (p. 823). PCT included psychoeducation in the first two sessions and thereafter focused on “discussing and reviewing general daily difficulties . . . [and] therapists helped patients identify daily stresses and discussed them in a supportive, non-directional mode” (p. 823). Therapists, who were female master’s degreeor doctoral-level clinicians, were randomly assigned to condition and given training and supervision in the respective treatments.

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

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Table 2 Evidence-Based Treatment Versus Present-Centered Treatment Effect Sizes for Targeted Variables, Secondary Variables, and Dropout in Five Studies Within study aggregate effect

Effect Variable

d

OR

p

d

Schnurr et al., 2003 Targeted CAPS Total PTSD Checklist Secondary GHQ SF 36 Mental SF 36 Physical Outpatient visits Inpatient visits Dropout

0.12 0.12 0.12

.278 .264

0.07 0.11 0.04 0.15 0.08

.508 .293 .676 .178 .451 < .001

0.09

3.15 McDonagh et al., 2006

Targeted CAPS Total Secondary BDI STAI TSI DES COOK STAXI QOLI Dropout

−0.22

−0.22

.435

−0.18 0.02 −0.41 −0.09 −0.54 −0.08 0.03

.519 .958 .152 .752 .060 .765 .909 .019

−0.18

7.06 Schnurr et al., 2007

Targeted CAPS PTSD Checklist Secondary BDI SAI QOLI SF Mental SF Physical ASI Alcohol ASI Drug Dropout

0.31 0.24 0.73

.041 .002

0.20 0.25 0.20 0.28 −0.11 0.00 −0.08

.092 .034 .084 .021 .332 1.000 .488 .002

0.14

2.27

Classen et al., 2011 Targeted PTSD Checklist 0.16 HIV Risk −0.41 Secondarya # of partners −0.22 Interpersonal problems 0.15 Depression 0.33

−0.12 .432 .108 0.06 .337 .430 .084

Table 2 Continued Within study aggregate effect

Effect Variable

d

OR

Anger/irritability 0.66 Dissociation 0.04 Sexual concerns −0.17 Dysfunctional sex −0.22 Impaired self-reference 0.12 Tension reduction 0.24 Posttraumatic growth −0.28 Attendance At least 1 session 2.46 Attend 75% 0.43 Sur´ıs et al., 2013 Targeted CAPS 0.16 PTSD Checklist 0.46 Secondary QIDS 0.19 Dropout 2.47

p

d

.001 .833 .371 .248 .528 .208 .196 .063 .089 0.31 .467 .038 0.19 .397 .092

Note. The effect size d is used for continuous variables whereas for dropout the odds ratio (OR) is reported. All values of d and OR were calculated from values given in the respective studies (e.g., means or standard deviations or from reported effect sizes). Positive values of d are in favor of the evidence-based treatment and odds ratios greater than 1 favor PCT. Significance levels p were calculated for d and OR with the usual formulas using two tails. CAPS = Clinician-Administered PTSD Scale; BDI = Beck Depression Inventory; QOLI = Quality of Life Inventory; GHQ = General Health Questionnaire; SF = Short-Form Health Survey; STAI = Spielberg State-Trait Anxiety Inventory; TSI = Traumatic Stress Institute Belief Scale; DES = Dissociative Experience Scale; COOK = Cook-Medley Hostility Scale; STAXI = State-Trait Anger Expression Inventory; ASI = Addiction Severity Index; QUIDS = Quick Inventory of Depressive Symptomology. a The secondary variables reported for Classen et al. are those that were not subscales of the targeted variables (C. Classen, personal communication, May 2, 2013).

The change in the CAPS from pretreatment to posttreatment is presented in Table 1, where it is clear that both treatments reduced PTSD symptoms over the course of therapy. PE, however, was superior to PCT on targeted variables (CAPS and PTSD Checklist) as well as several secondary variables (see Table 2); moreover, a significantly greater proportion of women in PE no longer met diagnostic criteria and achieved full remission. All effects in favor of PE were small with the exception of PTSD Checklist, which was moderate. PCT, as was the case in two of the trials reviewed above, however, resulted in significantly fewer dropouts (21.0% vs. 37.6%, OR = 2.27, p = .002). The differences between PE and PCT tended to diminish at the follow-up assessments.

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Present-Centered Therapy

Trial 4 The fourth trial to examine the efficacy of PCT was conducted by Classen et al. (2011), who compared a group format of PCT (present focused group therapy; PFGT), with traumafocused group therapy (TFGT), and a waitlist control group for adult survivors of childhood sexual abuse who were at risk for human immunodeficiency virus (HIV) infection due to risky sexual behavioral and substance use. In each active treatment condition clients received a total of 24 weekly sessions of treatment 90 minutes in duration. The 22 therapists in this study were provided with weekly supervision (1 hour per week) and videotapes of sessions were randomly selected by an expert clinician who provided feedback and evaluated treatment compliance. The primary difference between PFGT and TFGT was the focus of the treatment, as noted by Classen et al. (2011), “A major difference between a present-focused group and a traumafocused group is the emphasis on the here-and -now experience [in PFGT] as the vehicle for change, both behavioral and attitudinally” (p. 57). PFGT was guided by a manual developed by Classen, Butler, and Spiegel (2001), and as described by the manual, focused on the three major components of presentcentered treatments, namely psychoeducation (p. 44), modifying relational patterns (p. 15), and acquiring problem solving skills to be applied in current daily life (p. 56). Patients in this trial were 166 women who had been sexually victimized as a child and who engaged in risky sexual behavior or had substance use disorders. These patients were randomly assigned to PFGT, TFGT, or a waitlist control group. Primary outcome measures included HIV risk and PTSD severity. There were 10 secondary measures that were not subscales of the targeted measures and assessed various mental health domains and sexual behavior. Analyses were conducted at posttreatment and 6- month follow-up. Both treatments were efficacious. The change in PTSD severity for the two treatments is presented in Table 1 at the 6-month follow-up period. The effect sizes for the targeted measures (PTSD severity and HIV risk) compared to the waitlist control group for PCT were large (0.74 and 1.27, respectively) and statistically significant (p < .001). As presented in Table 2, analysis of the intent-to-treat sample yielded no differences between PFGT and TFGT for severity of PTSD, but an unexpected and statistically significant advantage for PFGT over TFGT was found for HIV risk, a variable which reflected a primary focus of the study. For the 10 secondary variables, there were no significant differences except for anger/irritability, which was in favor of TFGT (see Table 2). Attendance was assessed in two different ways. In all, 29.0% of TFGT patients never attended a session, whereas only 14.3% of PFGT patients never attended a session, although this result in favor of PFGT was not statistically significant (OR = 2.46, p = .063). On the other hand, of those who attended at least one session, 79.4% of TFGT patients attended at least 75% of the sessions versus 62.5% of PFGT patients, a result that favored

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TFGT, but was not statistically significant either (OR = 0.43, p = .089). Dropout, as traditionally defined, was not reported. The results of this of adult survivors of childhood sexual abuse were compelling because Classen et al. purposely enrolled CSA survivors who were engaging in risky sexual behavior and using substances, rendering the subjects similar to typical CSA survivors a mental health professional may see in his or her office and involved a relatively large sample (56 in PFGT and 55 in TFGT). Trial 5 Recently, Sur´ıs and colleagues (2013) compared CPT to PCT for veterans with PTSD due to military sexual trauma. In total, 129 veterans who satisfied study criteria were randomly assigned to the two treatments; however, one therapist failed to adhere to the CPT protocol and patients for this therapist in both treatments were omitted from the analysis, leaving the final analysis with 86 patients, 52 in CPT and 34 in PCT. CPT, based on the manual developed by Resick and Schnicke (1993), involved education, cognitive restructuring, and writing about trauma narratives. In this trial, the manual developed by Schnurr and colleagues and used in Schnurr et al. (2007; Clinical Trial #3 in this review) guided the delivery of PCT (P. Schnurr, personal communication, August 20, 2013). Both treatments showed large effects from baseline to posttreatment (see Table 1). At termination, there were no differences between conditions on the targeted variable CAPS or the secondary variable the Quick Inventory of Depressive Symptoms, but CPT was superior to PCT on the PCL (see Table 2). As in the other studies, the dropout rate for PCT (17.6%) was less than it was for the evidence-based treatment (CPT, 34.6%), although the difference was not significant (OR = 2.47, p = .092). The following conclusion was made by the authors. The current study demonstrated that CPT and PCT were both effective at reducing posttraumatic and depressive symptoms. Similar to findings from other randomized controlled clinical trials (McDonagh et al., 2005; Schnurr et al., 2007), PCT appeared to perform more like an active intervention rather than a comparison condition intended to control for the nonspecific aspects of therapy such as time and attention (p. 7).

Meta-Analysis Generally, the five trials demonstrated that PCT was as efficacious as evidence-based treatments in three of the five trials, with small to moderate differences in favor of the evidencebased treatment in the other two. To make sense of a number of trials where the results are not entirely clear, the method of choice is meta-analysis. Using the data discussed above, we calculated effect sizes for targeted variables, secondary variables, and dropout (d for the two former variables, as summarized in Table 2, and ORs for the latter), adjusted for small sample bias, and aggregated within study assuming that the outcome

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measures were correlated (see Hedges & Olkin, 1985; Wampold et al., 1997). We then tested the aggregate effects across studies using a random effects model, assuming that these five trials were drawn from a population of studies comparing PCT to an evidence-based treatment for PTSD. The results for targeted measures, secondary measures, and dropout were as follows. First, the aggregate effect size for targeted measures was small (d = 0.13) and not statistically significant (p = .219); the effects appeared to be homogeneous (Q = 7.97, p = .092). Second, the aggregate effect size for secondary measures was negligible (d = 0.09) and not statistically significant (p = .154); these effects also appeared to be homogeneous (Q = 2.13, p = .711). Third, in terms of dropout, omitting the Classen et al (2011) trial that did not report dropout unambiguously, 31.3% of the evidence-based treatment patients dropped out whereas only 14.3% of PCT patients dropped out, yielding an OR of 2.71 for staying in PCT versus staying in the alternative (p < .001).

Discussion Quality mental health care relies to a great extent on identifying treatments that have shown to be efficacious for particular disorders. Although evidence-based treatments for many disorders exist, the identification of additional evidence-based treatments is advantageous because it provides options to patients who might find other treatments uncomfortable or intolerable. Although there are a number of evidence-based treatments for PTSD, it appears that PCT is a viable, evidence-based treatment. In three of the five trials, PCT performed as well as the evidencebased comparisons. In the other two trials, the evidence-based treatment was superior to PCT on some measures. However, across the five trials, the meta-analysis showed no significant differences between PCT and the comparison evidencebased treatment on either targeted measures or secondary measures. As well, across the trials, PCT had significantly fewer dropouts. There is some ambiguity about the status of the ingredients of the various PCTs used in the clinical trials reviewed. Schnurr et al. (2007) noted that the PCT used in their trials was designed to “provide a credible therapeutic alternative to control for nonspecific therapeutic factors so that observed effects of prolonged exposure could be attributed to its specific effects beyond the benefits of good therapy” (p. 823). Spielmans and Gatlin (2007) argued that PCT in this study seemed more to “resemble a weak placebo intervention than a bona fide psychotherapy, . . . . [PCT] does not reference any established approach to psychotherapy, [and] appears not to be based on any psychological processes” (p. 2694). Nevertheless, as has been discussed, PCT indeed contains specific ingredients delivered deliberately, including psychoeducation regarding the impact of trauma on the client’s current life, a focus on altering present maladaptive relational patterns/behaviors, and the use of problem-solving strategies. A treatment that has a focus on

the present but does not contain these components is not appropriately labeled as present-centered therapy (see, e.g., Foa et al., 1991). It is important to note that PCT had significantly fewer dropouts than the evidence-based comparisons. Meta-analyses of dropout for PTSD generally have found that rates are comparable across treatments (Bisson et al., 2007b; Bradley, Greene, Russ, Dutra, & Westen, 2005; Hembree et al., 2003); however, recently Imel et al. (2013) conducted a meta-analysis of dropout from PTSD treatment using only direct comparisons and found no differences among dropout rates of various treatments except for PCT, which produced fewer dropout than other treatments, a result consistent with the present meta-analysis (which is not surprising given the overlap in studies analyzed). Perhaps the focus on present difficulties rather than the trauma is more tolerable to patients. If so, PCT has a considerable advantage relative to other treatments. It would appear that the evidence for PCT is sufficient to meet the criteria for an evidence-based treatment for PTSD (cf. Chambless et al., 1998) and Level A of the ISTSS scheme (Foa et al., 2009). Indeed, the Society of Clinical Psychology (Division 12 of the American Psychological Association) has determined that PCT is a research supported psychological treatment for PTSD with strong research support (Hajcak & Starr, n.d.). There are a number of limitations to the conclusions about the efficacy of PCT. First, the trials presented here have examined PCT for both military PTSD and childhood sexual abuse and consequently are not focused on one particular traumatic event. This is similar to the manner, however, with which other treatments for PTSD have been established. For example, the evidence for cognitive processing therapy, as indicated by the Society of Clinical Psychology (Hajcak & Starr, n.d.), is provided by three studies with different traumatic events, including military service (Monson et al., 2006), childhood sexual assault (Chard, 2005), and rape (Resick et al., 2002). A second issue is that the trials reviewed contained both group and individual therapy. The studies used to establish both PE and CPT as evidence-based treatments for PTSD, however, similarly contain both individual and group formats (see Chard, 2005; Foa et al., 1991, 1999, 2005; Keane, Fairbank, Caddell, & Zimering, 1989; Monson et al., 2006; see Hajcak & Starr, n.d.). A third issue is that the ingredients of PCT in the five trials were not identical. A perusal of evidence-based treatments for many disorders, however, reveals variations of a given treatment and consequently the treatments are not uniform. For example, CPT-C, CPT without the trauma narrative, is commonly used when patients are unwilling to participate in the exposure element of therapy. Moreover, manuals are updated and modified over time. The trials used to validate both PE and CPT have used different manuals or variations of the same manual. Clearly, future research is needed with regard to the therapeutic value of the ingredients of PCT and additional trials focused on PCT would provide important information about the ingredients of PCT.

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Present-Centered Therapy

The consideration of PCT as a viable treatment for PTSD adds to a growing list of evidence-based treatments for PTSD. Clearly more research is needed to understand the mechanisms of change in PTSD treatment (Ehlers et al., 2010; Wampold et al., 2010). Because patients seem to tolerate PCT better than other treatments and PCT appears to be as effective as other evidence-based treatments, PCT should be considered a firstline treatment for PTSD.

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Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. B. (1991). Treatment of post-traumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. Journal of Consulting and Clinical Psychology, 59, 715–723. doi:10.1037/0022-006X.59.5 .715 Foy, D., Glynn, S., Ruzek, J., Riney, S., & Gusman, F. (1997). Trauma focus group for therapy of combat-related posttraumatic stress disorder. In Session: Psychotherapy Practice, 3, 59–73. doi:10.1002/jclp.10066 Garcia, H., Kelley, L., Rentz, T., & Lee, S. (2011). Pretreatment predictors of dropout from cognitive behavioral therapy for PTSD in Iraq and Afghanistan war Veterans. Psychological Services, 8, 1–11. doi:10.1037/a0022705

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Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

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Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.