Helping Vulnerable Populations: A Comprehensive Review of theTreatment Outcome Literature on Substance Use Disorder and PTSD
Lisa M. Najavits1 and Denise Hien2
1Veterans Affairs Boston Healthcare System / Boston University School of Medicine2City College of New York
We review treatment studies for comorbid substance use disorder (SUD) and posttraumatic stressdisorder (PTSD). Results show positive outcomes on multiple domains. Most models had more effecton PTSD than SUD, suggesting SUD is harder to treat. Seeking Safety (SS) is the most studied model.It shows positive outcomes, and is the only treatment outperforming a control on both PTSD andSUD. Partial-dose SS had more mixed results than the full dose. This first-generation of PTSD/SUD re-search addresses complex samples excluded from “gold standard” PTSD-alone literature. Treatmentsfor PTSD/SUD are generally longer than PTSD-alone treatments and present-focused, emphasizingstabilization and coping. The few models with past-focused (exposure-based) components also incor-porated present-focused approaches for these vulnerable clients. We discuss public health perspectivesto advance the field. C© 2013 Wiley Periodicals, Inc. J. Clin. Psychol: In Session 69:433–479, 2013.
Complex trauma, posttraumatic stress disorder (PTSD), and substance use disorder (SUD) arelike parts of a prism—different lenses from which to see into clients’ often-tragic past. Thoughthey may have formal diagnostic representations that lead us to view them as separate entities,they are highly related in the day-to-day experience of clients’ lives. Yet it is only quite recentlythat attention has been directed toward linkages between these domains. Splits between mentalhealth and SUD treatment are well known, as is the fact that most clinicians never receive formaltraining in both. Clients have been left to try to integrate what our field historically has not.
Thus, it is heartening that the past several years have seen the emergence of new therapiesto address comorbidity and research to evaluate those therapies. This article is an attempt tosummarize where we are at this point: What models have been developed and tested? Whatthemes can we draw from the research on them? What next new directions are needed?
A major aspect that we hope to portray is that the data have many “stories to tell.” Withinthe framework of empirical studies, different details and ideas can be brought out. Our goal isto address topics that are meaningful to both clinicians and researchers. For example, for eachstudy we list how many hours of treatment were delivered, how the sample addressed complextrauma, the rate of minority representation, the types of clients who were excluded from thestudies (which is just as important as who was included), whether the clinicians conducting themodel were native to the setting (which bodes for stronger replication), and whether any negativeoutcomes occurred. We also apply uniform descriptors across studies so that one can comparea consistent set of standards across studies. Because of space limitations, a more detailed, fullyacademic version of this article is available from the first author, which provides a complete reference
This article was researched and written by the first author. The second author provided editorial feedbackand reported on her studies in the paper. Special thanks are extended to Martha Schmitz, PhD, for inspiringconversations related to themes in this article, and each of the authors’ research, clinical, and training teams,whose daily efforts toward improving the lives of complex PTSD/SUD clients is the backbone of our workand has been a large part of our attempt to contribute to this area. The first author names Gabriella Grant,Kay Johnson, Kevin Reeder, Martha Schmitz, Brenda Underhill, and Joni Utley. The second author namesAimee Campbell, Lisa Cohen, Lisa Litt, Gloria Miele, and Lesia Ruglass. This work was supported by theDepartment of Veterans Affairs, Clinical Sciences Research and Development.
Please address correspondence to: Lisa M. Najavits, VA Boston Healthcare System, 150 South HuntingtonAve., 116-B, Boston, MA 02130 617-299-1610. E-mail: [email protected]
JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 69(5), 433–479 (2013) C© 2013 Wiley Periodicals, Inc.Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.21980
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section, footnotes to explain technical points, and identification of methodological and statisticalissues in studies.
Method
This review includes all studies that address (a) a PTSD/SUD treatment model (one designed forthe comorbidity) or (b) a PTSD/SUD population, even if the treatment model was not designedfor the comorbidity. Exclusion criteria for studies are as follows: if they did not attempt to treatboth disorders and instead offer a posthoc analysis of their outcomes (e.g., Rotunda, O’Farrell,Murphy & Babey, 2008); had no SUD outcome (e.g., Bragdon & Lombardo, 2012); are solelya case study (Batten & Hayes, 2005) or case series without aggregated data (e.g., Berenz, Rowe,Schumacher, Stasiewicz & Coffey, 2012); are prevention rather than treatment (e.g., Danielsen,McCart, Walsh, de Arellano, White & Resnick, 2012; Zatzick et al., 2004); use a nonmanualizedtreatment (Steindl, Young, Creamer & Compton, 2003); evaluate a multicomponent intensivetreatment program rather than primarily a manualized model per se (Donovan, Padin-Rivera &Kowaliw, 2001); or take a model that has been studied for PTSD/SUD but is being applied toa sample that does not have SUD (e.g., Ford, Steinberg & Zhang, 2011).
In sum, our focus is on comprehensively summarizing the PTSD/SUD comorbidity treatmentliterature. Studies were obtained through existing literature reviews, online searches, referencelists of articles, and colleagues. Throughout, we use the term “PTSD” to broadly refer to thefull range of trauma-related symptoms, and SUD to refer to the full spectrum of both substanceabuse and dependence, unless otherwise indicated.
However, there are also topics we do not address, such as level of treatment attendance.Attendance is defined inconsistently in studies, sometimes with no clear denominator (howmany sessions were available to clients), sometimes reported only for those attending a certainamount of the study treatment, and sometimes not reported. Similarly, we do not report effectsizes, which are a metric of how much change occurred on an outcome. Many studies do notreport effect sizes or use different statistical methods for them, so they are beyond the scopeof this article. Finally, the treatment models themselves are not described, but that informationcan be obtained online or through the reference list from the first author. Regarding statistics,results are reported only for the standard .05 significance level (no trends). Finally, there werea few instances where, either for accuracy or to make equivalent comparisons across studies, aresult reported in Table 2 (see Appendix) may differ from that in the paper on the publishedstudy. Such discrepancies are documented in detail in the full academic version of this paperavailable from the first author.
Results
A description of each study (see Table 1 in Appendix) is organized by treatment model, and Table2 provides results of each study in relation to PTSD, SUD, and other outcomes. In a narrativesense, Table 1 represents “before and during” treatment and Table 2 is “after.” Several majorthemes are identified below that apply across studies, followed by a section related to specificmodels.
Key Themes
All of the Studies Address Complex Trauma/PTSD
The studies did not use a definition of complex trauma or complex PTSD as an inclusionarycriterion (identifier of who is to be included in the study), as there is as yet no formal definitionof these terms. Yet each study in fact did address a complex trauma/PTSD sample. Table 1,columns C, D, and E, indicate how each study relates to complex trauma/PTSD, in any or allof the following ways.
A multiply-traumatized sample and the presence of current trauma-related symptoms. Symptomswere in the form of PTSD (full or subthreshold), elevated trauma symptoms, or a positive screenfor major trauma history and/or symptoms. Most studies used well-validated assessments toidentify these.
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Comorbidity. To be included in this review, each study had to include comorbidity inthe form of a SUD sample, which was either defined through formal assessment of SUD orby virtue of being in a SUD treatment setting. The SUD in these studies was generally severe(usually dependence, not just abuse), chronic, often involved multiple substances, and includedboth alcohol and drugs (the latter being typically harder to treat). Further, although the studiesin this review do not provide a full diagnostic picture, any studies that did assess for additionaldiagnoses or symptoms found notable rates of them, such as major depression, Axis II disorders,or severe and persistent mental illness.
Childhood-based and/or repeated trauma. The clients in these studies often hadchildhood-based sexual and/or physical trauma, typically repeated, and interpersonally-based.
Multiple life burdens. A defining characteristic of complex trauma populations is thepresence of multiple life problems, in addition to formally diagnosed disorders. In these studies,per column D, these were clearly multiply-burdened samples, including homelessness, unemploy-ment, criminal justice involvement, multiple prior treatment episodes, low education, domesticviolence, suicidality, and violence.
Just reading some of the descriptors of these samples in Table 1 (column D) is heart-wrenching:“All had childhood-based PTSD; average of near-daily substance use; most had active suici-dal ideation and/or plan; all had substance dependence, primarily drug rather than alcohol”(Najavits, Schmitz, Gotthardt & Weiss, 2005); “Most were violent offenders with serious mentalillness, including bipolar/psychotic; child sexual abuse; average of 15 life stressors; in minimum,medium, or maximum security” (Wolff, Frueh, Shi, & Schumann, 2012); “Primarily unmarriedmothers, 35% with parental rights terminated by legal system, due primarily to SUD; 69% hadproblems with multiple substances, and substantial percentage used substance(s) daily; 77% hadprior SUD treatment; 35% had major depression, 19% bipolar I or II” (Young et al., 2004).
Minimal exclusionary criteria. The studies generally have low or at most moderateexclusions (see Table 1, column E), in contrast to the relatively high level of exclusions in theliterature on PTSD-alone (Bradley, Greene, Russ, Dutra, & Westen, 2005). Moreover, whenmajor exclusions are present, they are usually due to the study requiring a high level of care forthese vulnerable clients (studies #10, 22, 25, 33).
Finally, all but one of the treatment models themselves were explicitly designed for com-plex trauma/PTSD in terms of the above-mentioned characteristics: Concurrent Treatmentof PTSD and Cocaine Dependence (CTPTCD), later named Concurrent Prolonged Exposure(COPE); Creating Change (CC); Helping Women Recover/Beyond Trauma (HWR/BT); Inte-grated CBT for PTSD and SUD (ICBT); Seeking Safety (SS); Substance Dependence PTSDTherapy (SDPT); Trauma Adaptive Recovery Group Education and Therapy (TARGET); andTrauma Recovery Empowerment Model (TREM). All of these models were conceptualized fromthe start to address the multiple comorbidities and life problems of PTSD/SUD or complextrauma clients. In contrast, one additional model, Exposure Therapy plus SUD coping skillstreatment (EXP), used a PTSD-alone model in a PTSD/SUD sample.
The Studies’ Clinical Implementation Speaks to the Needs of the Population
There is much to be gleaned from Table 1, column B. For example, although the current researchculture focuses on short-term treatment models, notice how long the treatments were in thesestudies. They are wide-ranging but often were delivered in about 30–40 hours and sometimesquite a lot more. The study treatments were also added on to what were often quite high levelsof care (See Table 1, column C).
Column B also shows that the majority of studies used a group rather than individual modality,and within the group studies many used open rather than closed groups. Finally, many of thestudies used frontline clinicians who were native to the setting, often without advanced degreesor high levels of formal training. One study (#22) used a creative method of training its clinicians,
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who were in recovery themselves, by having them go through the model as participants prior toleading sessions. Another study used peer-led treatment (#9).
In sum, Column B provides a window into the needs of frontline settings that work with thesehighly complex populations. Aspects such as the number of hours of treatment, the use of groupover individual modality, and the use of a less highly trained workforce speak to the realities ofthese environments, where a good deal of complex trauma treatment is delivered. This picture isalso discrepant from many PTSD-alone treatment trials. (We are using the term “PTSD-alone”to differentiate the standard PTSD treatment literature from this review on comorbid PTSD-SUD.) Overall, the PTSD-alone literature has focused more on efficacy rather than effectivenessstudies. The former represents more pure academic research designed to have stricter control andmore rigorous scientific standards; the latter addresses real-world outcomes in regular practice.For example, PTSD-alone studies have focused largely on individual rather than group therapies;closed groups if they do use group modality; clinicians who are costly (highly trained, often withadvanced degrees, and receiving many hours of consultation and training as part of the studies;Karlin et al., 2010).
PTSD-alone studies have also consistently excluded more vulnerable populations such asthose who have problems with homelessness, domestic violence, suicidality, violence, seriousand persistent mental illness, and SUD (particularly substance dependence and drug disordersrather than alcohol). The PTSD treatment field does produce positive outcomes with short-termmodels of 12–20 sessions (Institute of Medicine, 2007), but not generally on these types of highlycomplex clients. And, even with its successes, it is also true that a substantial subset of clientsremains symptomatic, and go through repeated episodes of these and other treatments.
All Studies Using a Past-Focused (Exposure) Approach Combined it With aPresent-Focused (Coping) Approach
A major current discussion in the field is the relative merit of present-focused versus past-focusedapproaches to PTSD treatment. Broadly speaking, models that focus on exposure-based or otheremotionally intense exploration of the trauma narrative are termed here past-focused, in contrastto models that focus on current coping skills and psychoeducation, which are present-focused(Najavits, 2013).
A note on terms: The term trauma-focused is sometimes used to refer to exposure-basedmodels. However, we view that as a misnomer as all present-focused PTSD models, includingthose covered in this review, directly and strongly “focus on trauma.” The difference is how theyapproach it. Exposure-based models focus primarily on the past by exploring trauma memoriesand associated feelings, thoughts, and body sensations. Present-focused PTSD models explicitlyomit detailed exploration of the past, typically in the service of helping stabilize the client,and instead focus primarily on coping skills and psychoeducation. We observe too that theterm “nontrauma-focused treatment” to refer to these present-focused PTSD models is alsoproblematic as it labels them solely by what they are not; it is equivalent to referring to womenas “non-men” or children as “non-adults.” Present-focused approaches have a rich content ofcoping skills and psychoeducation that is better captured by a meaningful label.
Terminology aside, in recent years, there has been growing interest in applying past-focusedPTSD models to SUD, which historically was always viewed as outside the purview of suchmodels. The phrase, “get clean and sober first, and then work on PTSD” was the predominantmessage for most of the 20th century (Najavits, 2002). In part, this perspective was based ondocumented cases (Pittman et al., 1990) and other reports of increased substance use or otheriatrogenesis from trying to move clients into emotionally intense trauma narratives before theywere stable enough to tolerate it, sometimes called “opening Pandora’s box” (Hien, Litt, Cohen,Miele & Campbell, 2009). It has also been based on differences in workforce, culture, resources,and modality of treatment in mental health versus SUD treatment settings (Najavits, 2013).The stage-based approach to PTSD treatment, in which present-focused stabilization occursfirst before moving into past-focused exposure, has been an important historical framework(Herman, 1992), and remains one that is still widely endorsed by PTSD experts (Cloitre, Courtois,Charuvasta, Carapezza, Stolbach & Green, 2011).
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However, in recent years there has been a new development of trying to evaluate whetherpast-focused approaches can be used safely with complex PTSD/SUD populations. (To see theshift in enthusiasm for applying past-focused models to PTSD/SUD, compare, for exampleFoa, 2000, to Riggs and Foa, 2008). Six studies in this review have attempted this, using fourdifferent models: CTPCD (#30), later reworked as COPE (#34); Exposure (EXP; #33); SS-plus-Exposure-Therapy-Revised (#31), later reworked as CC (#35); and SDTP (#32). Severalimportant lessons can be gleaned from these studies, albeit based on an early stage of literatureat this point. First, it is possible to use exposure-based models with these complex clientswhen using the modifications used in these studies. The latter is emphasized because all six studiesmarkedly changed classic exposure for PTSD. Two models, COPE and SDTP, took the approachof combining an existing empirically validated model already developed for PTSD (such as PE)and SUD (such as relapse prevention). Another, CC, was developed as a companion to present-focused SS, and has extensive preparation and decision-making tools for deciding whether aclient is ready for exposure, as well as broadening exposure to a gentler version. Finally, the EXPstudy required all clients to be in highly intensive SUD treatment and to verify abstinence priorto starting. That study was primarily a laboratory experiment rather than a treatment trial, butdoes report outcome results and so is included.
With such extensive modification to classic exposure, all six studies found some positive out-comes and no notably negative outcomes, which is an important take-home message. However,two of the three randomized controlled trials (RCTs) conducted thus far (SDTP and COPE)did not outperform standard SUD treatment to any notable degree. In the SDTP study (#32)there was no difference between it and 12-Step Facilitation therapy on any outcome. And COPE(#34) did not outperform the control (SUD treatment-as-usual) on any substance use variablein the study at any timepoint, and only outperformed on PTSD at 9-month follow-up, not atthe end of treatment point for COPE (Najavits, 2012). The EXP study (#33) did outperformthe control, but only on PTSD (SUD and other variables were not reported), and only in thecontext of mandatory SUD treatment and major exclusions for complex clients (see Table 1,column E).
Finally, Table 1 indicates that all six studies that included a past-focused component weredelivered in individual modality rather than group, and most tended to restrict to a morenarrow sample than the present-focused studies, in keeping with the PTSD-alone literature.It is also evident that the CTPCD and EXP (#30, 33) studies only report outcomes on aminority of their sample, and SDTP is unclear on the percentage it reported on (see Table 2,column A).
The Studies Have Variable Methodological Rigor and Clearly More Research is Needed
Also evident from the tables is that the mantra of research—“more research is needed”—holdsvery true in this area of work. There are relatively few RCTs compared with pilots and controlledtrials. Moreover, there were some consistent methodological weaknesses in the studies. Thesecan be useful for clinicians to keep in mind when considering adoption of treatments and whenreading outcome articles, as well as for improving future research in this area.
Absence of end-of-treatment outcomes. Per Table 2, a surprising number of studiesreport no data at the end of treatment, but instead only at follow-up points. One study, forexample, has a treatment that ends at 4 months, but there are no outcome data until 12 months(#13). Yet from baseline to end of treatment is the most rigorous timeframe from which tounderstand the effect of a treatment model, and end of treatment to follow-up to understandwhether clients maintained gains. One study collected data at what appears to be the end oftreatment, but did not compare it separately to either baseline or follow-up (#25). There arecertainly interesting questions, from a health services perspective, that can be addressed byfollow-ups months after the study treatment has ended, but the “black box” of the follow-upperiod, during which clients may be receiving all sorts of unknown treatments, makes it lessuseful for understanding how to improve treatment models.
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Omission of key information. Also notable was the large amount of missing informa-tion. Published reports typically lacked some of the following details: attendance data and effectsizes (mentioned earlier); whether any negative outcomes occurred; clear reporting on timing(i.e., when the study treatment ended, how much study treatment was delivered); the amountof training and supervision clinicians had to undergo in the study treatment; treatments clientswere engaged in aside from the study treatment; sample sizes at each stage of the researchand in all statistical reporting; and full-intent-to-treat analyses (reporting on all clients whoentered the study, rather than just those who completed treatment as in #22 and #33). And,although not standard at this point, a wish-list for additional information would include uri-nalysis/breathalyzer to verify substance use self-reports, scales to measure complex trauma andintergenerational trauma, treatment satisfaction by both clients and clinicians (the latter is virtu-ally never reported, the cost of the treatment (even in some basic form), the treatment developer’slevel of involvement in the research, and use of only psychometrically valid instruments for keyconstructs. Such details matter, in terms of both being able to interpret the results of studies andalso for later implementation of models in practice.
Questionable aspects. Occasionally, there was some reporting that was puzzling. Someexamples are as follows: A study treatment that had 52% more clients randomized to it thanto the control condition, with no reason given (#25); report of a “decrease in substance use”without adequate data or a statistical test to support that (#22); covarying out a set of variablesthat were not statistically different between treatment conditions at baseline, resulting in positiveoutcomes for the study treatment that otherwise did not exist (#23); mention of a treatmentbeing “superior” to another based on a trend on one variable and no other significant differenceon primary outcomes between study conditions (#26); stating a difference existed at a 6-monthtimepoint that was not there (#28); stating that a study had adequate sample size though itobtained 26% less than was required by the power analysis listed in the paper (#18); reportingfollow-up results when just 13% (#30) or 27% (#14) of the study treatment sample was stillavailable. Thus, one should always read beyond the study abstracts as sometimes they are rosierthan actual verifiable results in the text, and may omit findings that do not put the study treatmentin a positive light.
Yet it is clear that many of the studies were conducted under less than optimal conditions andsome were unfunded, and the teams were sometimes not academics but rather more clinicallyoriented. The remarkable big picture point is that the studies were done on complex populationsthat heretofore have been largely unstudied in the treatment outcome field. Thus, the weaknessesof these studies, as reflected in their methodological and reporting flaws, are noted here so asnot to imply that the literature is further along than it is. Although it is a dramatic improvementover the virtual absence of such studies a decade ago, the hope is that the next decade will seeincreasing rigor.
Summary of Results on Models
About Table 2
Table 2 provides a wealth of information. To better understand results listed there, the followingpoints may be helpful.
The goal of the table is to provide comprehensive data on all models and all variables,addressing both the end of treatment and follow-up results. In other words, do clients improvefrom baseline to end of treatment (columns C, D, E)? And do they improve at follow-up, i.e., atsome timepoint months after the end of the treatment (column F)? Within each of these centralquestions, results are organized into three types of outcomes: (a) trauma/PTSD, (b) SUD, and(c) “other variables,” which refers to all other outcomes studied.
Throughout, results are reported only for psychometrically valid measures. Also, given theearly stage of literature and the often small sample sizes (resulting in statistical lack of power),only significant outcomes are listed.
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All controlled studies and RCTs are, by their design, comparing the study treatment to acontrol such as another treatment or treatment-as-usual. For such studies, results are listed asfollows. If the study treatment outperforms the control, the result is shown in boldface andunderline (regardless of whether the control also improves, as our primary goal is to identifywhether there is any added benefit for the study treatment). If the study treatment does notoutperform the control, and both conditions improve, the result is underlined only. This is usefulbecause it gets away from just the “horse race” results reported in many reviews, which indicateonly whether one treatment outperformed another. From a public health standpoint, a morerelevant question is, “In what ways does the study treatment outperform the control, and inwhat ways do both improve?” Thus, Table 2 is constructed to help the reader see the full bodyof evidence so as to be able to identify overarching patterns.
Column A provides the percentage of the original sample that the investigators sought toreport on in their outcomes. This is important because (as is evident from looking down columnA) some investigators aim to report outcomes for the entire initial sample, which is consideredthe gold standard known as “full intent to treat” reporting. It is the least biased because it asks,“How did everyone do who enrolled in the trial?” Other studies have some smaller proportion,which is also legitimate but addresses a different question, such as in a pilot study where thegoal may be: “How did clients do if they attended at least one session [or four sessions, etc.] ofthe treatment?” In Column A, studies that have less than the full intent to treat (100%) data arelisted by their percentage. In most studies, the majority of participants were reported on. But ina few studies, it is a minority percentage, and thus limits the generalizability of the results. Anystudies with a minority of the original sample being reported on are noted with this symbol toindicate absence of sufficient sample and thus caution needed in interpreting the study results: ♦.
Findings Across Models
The following points become clear when looking across Table 2.
The models generally show positive outcomes. Notice the many “yes” results acrossthe table, each indicating a positive outcome. This is good news because it means that clientsimproved over time when given these manualized models of treatment that were designed totarget their problems. They improved, depending on the study, in many different domainsincluding trauma/PTSD, SUD, and areas such as psychopathology, functioning, cognitions,self-compassion, and coping skills. There were few negative outcomes (worsening over time),and treatment satisfaction was generally strong in studies that addressed it. However, it is alsoimportant to keep in mind the context of these studies. Clients were almost always in additionaltreatments while receiving the study treatment, and those additional treatments were rarelyidentified in terms of amount, type, or quantity. Additional treatments included psychiatricmedication, other psychotherapies, 12-step, intensive partial program, and methadone mainte-nance, for example. Thus, future research is needed to help address the interaction between studytreatments and additional treatments. Also, other questions would be needed for a full under-standing: Are there different subgroups of clients who improve more than others in treatment?How do clinicians differ in delivering the treatment (as therapist factors are one of the mostpowerful influences on outcomes; Najavits & Weiss, 1994)? How much treatment is needed toproduce positive outcomes?
There are some findings for treatments outperforming the control. This is the “horserace” question, asking whether the study treatment did better than what it was being comparedto (the design of all studies in Table 2 listed as “controlled trial” or “RCT”). The table indicatesthat there were various findings for the models outperforming the control, although not always,and not for all models. (Look for the findings that are both in boldface and underlined, notunderlined alone, to locate the ones that did occur). Those that showed any difference were asfollows: SS (#13, 14, 15, 16, 17, 18, 19, 20, 21); ICBT (#25); TREM (#27, 29) and BCM/TREM(#28); EXP/SUD (#33); and COPE (#34). A few models showed no significant differences fromthe control (SDPT, TARGET, GRT). Even the models that did show a difference sometimes
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only showed it for one variable or scale, so it is important to recognize that at this early stageof work, it is not yet clear what the future holds in terms of range, degree, and sustainability ofchanges produced by any one model.
It is also important to recognize that treatments differed in how long they were delivered(e.g., they varied extensively in number of hours of treatment, per Table 1 and, by implication,likely cost). There are also many other relevant contextual factors (see the paragraph above). Itis also notable that there were no instances of the control outperforming the study treatment.(The only ones reported was for GRT, #23, on one variable and only in the overtime, notbetween-conditions analysis, and for SS, #21, on one secondary analysis variable [alcohol useby stimulant users]). Finally, it is just as important to notice how often both the study treatmentand the control showed improvement, without a difference between them (see all instances inthe table of the underlined, but not boldface, results). This happened quite frequently acrossthe table, indicating that the study treatment was not more helpful than the control on thosevariables.
Overall, then, it is evident that there were some positive findings for some of the studytreatments outperforming the controls. Among the models that did evidence outperforming acontrol, there were also differences in the number and range of findings achieved, per Table 2.And there were also quite a few instances where both the study treatment and the control showedimprovement, with no difference between them.
When there were differences between conditions, they were more on PTSD or othermental health variables, and less often on SUD. This is important as it may indicate thatin these complex comorbid clients, the PTSD and mental health issues may be easier to treator sustain over time than SUD outcomes. That remains a question for future research but doesfit clinicians’ perceptions (Back et al., 2009). It also fits the larger body of work wherein PTSDis typically conceptualized as amenable to short-term treatment and resolution, whereas SUD(dependence in particular) is conceptualized as a chronic relapsing disorder (Arria & McLellan,2012). The pattern seen in Table 2 may also reflect that clients were typically in SUD treatmentswhile in the study treatment. In terms of specific models in Table 2, study treatments that showedthis pattern of outperforming the control on PTSD but not SUD occurred for ICBT (#), BCM(#28), and COPE (#34). The only models in which the study treatment outperformed the controlon SUD were SS (e.g., #16,17, 18) and TREM (#29). The only model thus far that outperformedthe control on both PTSD and SUD was SS (see next section).
SS
We will summarize results on SS here, as it has been the subject of the majority of studies.
SS is the most rigorously studied treatment thus far for PTSD/SUD. It has beenstudied in 22 of the 35 studies in this review: 13 pilots, three controlled studies, and six RCTs(one a hybrid RCT). It is also the model with the most number of independent studies, which,as noted earlier, are less subject to positive bias. Consistent with all the studies in this review,clients in SS studies were consistently in the realm of complex trauma/PTSD, with comorbidity,high severity and chronicity, and multiple life problems. Various studies had strong minorityrepresentation. There were relatively few exclusionary criteria for clients, and in many studiesclinicians were native to the setting. SS has been studied primarily in group modality (18 of the22 studies), with most of these open rather than closed groups, and usually singly led rather thanco-led. Overall, these characteristics are representative of frontline SUD treatment settings.
Some studies are partial-dose SS only. Six of the studies are partial-dose SS studies,using 24% to 48% of the model (#10–12, 19–21), including the largest investigation of SS to date,the National Institute on Drug Abuse Clinical Trials Network (CTN) study, which used 48% ofthe model in 6 weeks (#21). “Partial-dose” refers to the number of SS topics used. The CTNstudy, for example, used 12 of the 25 SS topics. Partial-dose does not refer to a total numberof hours conducted per se as SS does not have a defined dose in that sense (per the SS manual
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sessions can vary in duration of session and timing of sessions, based on the needs of the clientand clinician). Partial-dose studies address a different question than full dose SS studies. Theyask, “How well does SS work when only a segment of the content is delivered?” which in all sixpartial-dose studies thus far was less than half of its content. (Thus far, all reviews that includeSS omit this important point, e.g., Bernardy et al., 2013; Torchalla, Nosen, Rostam & Allen,et al. 2012, van Dam, Vedel, Ehring & Emmelkamp et al., 2011.)
SS has shown positive outcomes across studies generally. Across studies SS has hadnumerous positive outcomes on PTSD, SUD, and other variables (the many “yes” results inTable 2). In the controlled trials and RCTs, SS outperformed the control on PTSD but notSUD in some studies (#13, 14, 15, 20); on SUD but not PTSD in another (#18); and in somestudies, on both PTSD and SUD (#16, 17) and on both PTSD and SUD among more severeSUD patients (#21, on secondary analyses of subgroups). Most also found SS outperformed thecontrol on other variables, such as psychopathology, cognitions, and coping. Thus, in keepingwith the finding noted for other models, it appears to be easier to obtain results for PTSD andmental health outcomes than for SUD, although SS has shown demonstrable results on SUD insome studies as well.
Also, consistent with our earlier summary of Table 2, there are various instances of bothSS and the control improving. Studies of partial-dose SS have had mixed results, with somefinding stronger results than others (see studies #10–12, 18–20). In the partial-dose CTN study,secondary analyses on subgroups found SS to outperform the control in various results (andespecially with more severe SUD clients), and in only one instance found the control outper-forming SS (#21). When treatment satisfaction has been studied it has consistently been strong.Also, greater dosage has been shown to positively affect outcomes (#13, #19), and in two studiesSS obtained higher attendance than the control (#18, 21). SS has achieved various positiveoutcomes even with delivery by case managers (#14), by peers (#9), and with client who havepathological gambling disorder (#8). Thus far, there appear to be no discernable patterns ofdifference in studies based on factors such as individual versus group delivery, level of minor-ity representation, or type of clinicians delivering it, but formal comparative studies would beneeded to address these topics.
Finally, the model has been found to be very safe (Killeen et al., 2008), with no regular orfrequent pattern of worsening, though an occasional finding has occurred per Table 2 on asingle variable. SS is listed as having strong research support by various professional entities,based on their criteria sets, including Level A by the International Society for Traumatic StressStudies, and “strong research support” by Divisions 12 and 50 of the American PsychologicalAssociation.
Summary and Discussion
In the pages above, we explored the topic of treatment outcome studies for complex PTSD/SUD.Below is a recap of some of the key findings, although this is clearly an early stage literature withfar more research needed to draw firm conclusions.
The majority of treatments developed for these complex PTSD/SUD clients are present-focused approaches, emphasizing stabilization, coping skills, and psychoeducation, and, bydesign, not including past-focused (e.g., exposure-based) emotionally intense components. Thesemodels, all of which have had one or more empirical studies, are HWR/BT, ICBT, SS, TARGET,and TREM.
In recent years, a few models have also been developed or studied that include a past-focusedcomponent: CTPCD, later named COPE, CC, and SDPT. Each of these represents majoradaptations of classic exposure-based models to make them safe and effective for PTSD/SUDpopulations, who are perceived as more vulnerable and challenging to treat than PTSD-alone.Each of the resulting models is a present-focused plus past-focused combination, not a past-focused intervention delivered alone.
Overall, the studies in this review represent a more complex clientele than has been studiedin most of the gold standard PTSD-alone outcome literature thus far. A typical description
442 Journal of Clinical Psychology: In Session, May 2013
comes from study #13: “In addition to co-occurring SUD/psychiatric disorders, most had expe-rienced child abuse, been homeless, served jail time, and suffered interpersonal abuse in the past6 months; SUD was primarily drugs rather than alcohol (with methamphetamine common).”
Thirty-five studies are described (Table 1) and their outcomes listed (Table 2). Overall, resultsshow numerous positive outcomes across the domains of PTSD, SUD, and other variables,including psychopathology, cognitions, and coping. However, it also appears that SUD is harderto treat than PTSD (most models having more effect on the PTSD than SUD when studied incontrolled or randomized trials). The “controls” in these trials have almost uniformly beenSUD treatments, whether as treatment-as-usual SUD treatments or formal manualized SUDtreatments (e.g., relapse prevention or individual drug counseling). Thus, it may be the casethat the PTSD/SUD treatments were duplicating the effort already being focused on SUD.However, it may also be the case that SUD is simply harder to treat. The conceptualizationof SUD (especially substance dependence) as a “chronic relapsing illness,” much like diabetes,rather than a resolvable acute syndrome (as PTSD is currently conceptualized in gold standardPTSD-alone treatments currently), may be useful to keep in mind in future research.
All treatments studied showed a positive effect in pilot studies. In controlled trials or RCTs,most treatments evidenced at least one variable or scale in which it was superior to the control,although some did not. Also, both the study treatment and the control showed improvementon various outcomes in various studies, highlighting the point that it is not always differentialoutcomes that are important, but also looking at ways in which both show effects.
SS is the most studied model, with 22 of the 35 studies. It is the only treatment thus far thathad an effect on both PTSD and SUD relative to a control (in controlled trials or RCTs). Insome studies it shows a superior effect on PTSD and in one study it is superior just on SUD.Six of the SS studies, including the large CTN study (#21), were partial-dose studies with lessthan 50% of the SS content delivered, a fact omitted in prior literature reviews that covered SS.Overall, various positive SS outcomes are listed in Table 2 across a diverse range of studies. Twostudies have found that greater dosage has been shown to positively affect outcomes (#13, #19),and in two studies SS obtained higher attendance than the control (#18, 21). A few isolatednegative outcomes were found on single variables; but overall research shows it to be a highlysafe model. SS studies have largely been group modality studies, typically open groups, withclinicians native to the setting, and by independent investigators. As such, the literature on itlargely represents effectiveness rather than efficacy studies, and evidences its ability to producepositive outcomes in real-world conditions. However, more studies are clearly needed.
Several important aspects were beyond the scope of this review: comparison of attendancepatterns, effect sizes (degree of change), and statistical meta-analysis. However, given the currentstate of the literature (see the next point), meta-analysis appears premature.
The studies reviewed are impressive in being the first generation of research to focus on thecomplex PTSD/SUD clientele that have consistently been excluded from most prior outcomeresearch. However, the studies contain notable weaknesses in both design and reporting. Theyoften lack end-of-treatment outcomes (which are the most relevant to understand the effectof models and to improve them). In addition, they are typically pilot studies conducted inconjunction with variable amounts of other treatments that are unspecified, generally do notreport on the full array of comorbid conditions in their samples, and tend not to use urinalysisto verify SUD self-reports.
A Public Health Perspective
Beyond the above findings, it is useful to address the treatment needs of these clients froma broader public health lens. There is no model yet in existence nor is there one likely to bedeveloped that can resolve quickly what for many of these clients are decades of abuse, neglect,violence, substance use, and the host of associated life problems that co-occur with these, such ashomelessness, criminal justice involvement, job problems, poverty, discrimination, and physicalhealth problems. They are a multiply burdened segment of the population with high chronicity(Brown, Huba, & Melchior, 1995). They often have the least resources for care and receive
Review of Treatments 443
treatment from some of the least trained clinical staff. They often end up in public healthsystems of care.
Thus, some important questions for the next generation of research include the following, interms of behavioral treatments.
What length of treatment is actually needed for these clients? As shown in Table 1, treatmentsin this study had wide-ranging length, but few treatments were actually very brief, suggestingthat for complex PTSD/SUD clients, longer treatment is perceived as necessary. In keeping withthis, Dialectical Behavior Therapy, one of the most widely adopted treatments for complex pop-ulations, is designed as one year of approximately 182 hours of group and individual treatment(see Landes, Garovoy & Burkman, this issue). Various PTSD-alone gold standard treatmentshave been identified as short-term models of 12–20 sessions, but they are gold standard only fora narrow segment of PTSD clients, and certainly not as yet gold standard, much less empiricallyvalidated, for the types of high complexity clients covered in this review. (There have been a fewinitial studies in which past-focused models have been tried with complex PTSD/SUD clientsper Tables 1 and 2. But they have always been combined with present-focused models and madeinto longer treatments, as described earlier.)
What is consistently missing from the outcome literature is a clear picture of treatments thatclients had prior to the study treatment and after the study treatment. Many if not most ofthese clients are “repeat customers” who cycle through many rounds of treatment, yet this is notcaptured in the current zeitgeist of how models are studied. It is as if we are watching just themiddle few minutes of a movie and have missed the much larger story before and after. Evenstudies with follow-up periods rarely report on what treatments client received during that timein type, amount, and level of helpfulness.
Complex comorbid clients at the severe end of the spectrum may need models that provideongoing support rather than a time-limited course. Certainly for less severe, less complex clients,treatment may work as envisioned in manuals with a limited number of sessions. But others mayneed support for a long time. This is reflected in the wisdom of 12-step approaches that provideongoing, free, continuous support to help maintain abstinence from substances and that grewup as a grass-roots model developed by addicts themselves. In the PTSD field and mental healthbroadly, there is currently no widespread supportive resource of this type. Findings consistentlyshow that SUD clients, including those with PTSD, who attend 12-step groups are more likely tosustain positive outcomes. For clients in the severe end of the spectrum, SUD may be more of adisorder like diabetes that requires long-term management. Becoming creative about developingresources for complex clients (beyond 12-step groups) may be an important public health goal.Some of the models identified in this review can perhaps be used in such ways.
It is crucial to focus more on which treatments, and what about those treatments, are mostappealing, easy to implement, and low cost for clinicians and clients in public health systems ofcare, in relation to a given unit of outcome. “Horse race” comparisons (which rarely evidencepowerful or consistent differences between well-developed models) are increasingly less relevantthan determining which models clients want to engage in and which their workforce can deliver,within the realities of the setting. Major reviews and several decades of research indicate thatwell-crafted models do not typically outperform each other (Benish, Imel & Wampold, 2007;Bradley et al., 2005; Garfield & Bergin, 1998; Imel, Wampold, Miller & Fleming, 2008; Powers,Halpern, Ferenschak, Gillihan & Foa, 2010). However, they may differ in other important waysin terms of these other aspects (appeal, ease of implementation, and cost). A model that hasslightly less effect on outcome but is much stronger on these factors may be a good public healthchoice. Thus far, such aspects have not been researched in the PTSD/SUD field in relation totreatment models.
It is also essential to attend more to the clinicians treating these clients, many of whomhave substantial histories of trauma and/or addiction themselves. They typically manage largecaseloads of complex clients, often without sufficient support or training. There is little empiricalresearch on how to best select and retain them, and to support them in their work. The adventof evidence-based manuals is important, but their workforce needs go beyond manuals.
Overall, as this review shows, there have been creative and strongly humanitarian attempts tocreate various treatment manuals that are sensitive to the trauma, comorbidity, and widespread
444 Journal of Clinical Psychology: In Session, May 2013
suffering endured by complex PTSD/SUD clients. Manualized models can bring a high levelof innovation and inspiration to clinical work. The hope is that in the decades ahead, empiricalefforts will continue to expand our understanding of how to best help the broadest range ofthese clients.
Selected References and Readings
Amaro, H., Dai, J., Arevalo, S., Acevedo, A., Matsumoto, A., Nieves, R., & Prado, G. (2007a). Effects ofintegrated trauma treatment on outcomes in a racially/ethnically diverse sample of women in urbancommunity-based substance abuse treatment. Journal of Urban Health, 84, 508–522. [Note: Amaroet al., 2007b is listed in the fully referenced version of this paper available from the first author.]
Benton, D. M., Deering, D. E. A., & Adamson, S. J. (2012). Treating co-occurring posttraumatic stressdisorder and substance use disorders in an outpatient setting in New Zealand. New Zealand Journal ofPsychology, 41, 30–37.
Boden, M. T., Kimerling, R., Jacobs-Lentz, J., Bowman, D., Weaver, C., Carney, D., . . . Trafton, D. A. (2012).Seeking Safety treatment for male veterans with a substance use disorder and PTSD symptomatology.Addiction, 107, 578–586.
Brady, K. T., Dansky, B. S., Back, S. E., Foa, E. B., & Carroll, K. M. (2001). Exposure therapy in thetreatment of PTSD among cocaine-dependent individuals: Preliminary findings. Journal of SubstanceAbuse Treatment, 21, 47–54.
Coffey, S. F., Stasiewicz, P. R., Hughes, P. M., & Brimo, M. L. (2006). Trauma-focused imaginal exposure forindividuals with comorbid posttraumatic stress disorder and alcohol dependence: revealing mechanismsof alcohol craving in a cue reactivity paradigm. Psychology of Addictive Behaviors, 20, 425–435.
Cook, J. M., Walser, R. D., Kane, V., Ruzek, J. I., & Woody, G. (2006). Dissemination and feasibility ofa cognitive-behavioral treatment for substance use disorders and posttraumatic stress disorder in theVeterans Administration. Journal of Psychoactive Drugs, 38, 89–92.
Covington, S., Burke, C., Keaton, S., & Norcott, C. (2008). Evaluation of a Trauma-Informed and Gender-Responsive Intervention for Women in Drug Treatment. Journal of Psychoactive Drugs (SARC Supple-ment), 5, 387–398.
Daoust, J.-P., Renaud, M., Bruyere, B., Lemieux, V., Fleury, G., & Najavits, L. M. (2012). Posttraumaticstress disorder and substance use disorder: Evaluation of the effectiveness of a specialized clinic forFrench-Canadians based in a teaching hospital. Manuscript submitted for publication.
Desai, R. A., Harpaz-Rotem, I., Najavits, L. M., & Rosenheck, R. A. (2009). Seeking Safety therapy:Clarification of results. Psychiatric Services, 60, 125.
Desai, R. A., Harpaz-Rotem, I., Rosenheck, R. A., & Najavits, L. M. (2008). Effectiveness of treatment forhomeless female veterans with psychiatric and substance abuse disorders: Impact of “Seeking Safety”on one-year clinical outcomes. Psychiatric Services, 59, 996–1003.
Fallot, R. D., McHugo, G. J., Harris, M., & Xie, H. (2011). The Trauma Recovery and EmpowermentModel: A quasi-experimental effectiveness study. Journal of Dual Diagnosis, 7, 74–89.
Frisman, L., Ford, J., Hsui-Ju, L., Mallon, S., & Chang, R. (2008). Outcomes of trauma treatment using theTARGET model. Journal of Groups in Addiction & Recovery, 3, 285–303.
Gatz, M., Brown, V., Hennigan, K., Rechberger, E., O’Keefe, M., Rose, T., & Bjelajac, P. (2007). Effectivenessof an integrated, trauma-informed approach to treating women with co-occurring disorders and historiesof trauma: The Los Angeles site experience. Journal of Community Psychology, 35, 863–878.
Ghee, A. C., Bolling, L. C., & Johnson, C. S. (2009). The efficacy of a condensed Seeking Safety interventionfor women in residential chemical dependence treatment at 30 days posttreatment. Journal of Child SexAbuse, 18, 475–488.
Hien, D. A., Cohen, L. R., Miele, G. M., Litt, L. C., & Capstick, C. (2004). Promising treatments for womenwith comorbid PTSD and substance use disorders. American Journal of Psychiatry, 16, 1426–1432.
Hien, D. A., Wells, E. A., Jiang, H., Suarez-Morales, L., Campbell, A. N., Cohen, L. R., . . . Nunes, E. V.(2009). Multisite randomized trial of behavioral interventions for women with co-occurring PTSD andsubstance use disorders. Journal of Consulting and Clinical Psychology, 77, 607–619. [Note: citationsfor secondary analyses of this study are in the fully referenced version of this paper available from thefirst author.]
Lynch, S., Heath, N. M., Matthews, K. C., & Cepeda, G. J. (2011). Seeking Safety: An intervention fortrauma exposed incarcerated women? Journal of Trauma and Dissociation, 9, 301–319.
Review of Treatments 445
McGovern, M. P., Lambert-Harris, C., Acquilano, S., Xie, H., Alterman, A. I., & Weiss, R. D. (2009). Acognitive behavioral therapy for co-occurring substance use and posttraumatic stress disorders. AddictiveBehaviors, 34, 892–897.
McGovern, M. P., Lambert-Harris, C., Alterman, A. I., Xie, H., & Meier, A. (2011). Behavioral therapyversus individual addiction counseling for co-occurring substance use and posttraumatic stress disorders.Journal of Dual Diagnosis, 7, 207–227.
Messina, N. P., Calhoun, S., & Warda, U. (2012). Gender-responsive drug court treatment:A randomized controlled trial. Criminal Justice and Behavior, online version 10/2/2012doi:10.1177/0093854812453913
Mills, K. L., Teesson, M., Back, S. E., Brady, K. T., Baker, A. L., Hopwood, S., . . . Ewer, P. L. (2012). Inte-grated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence:a randomized controlled trial. Journal of the American Medical Association, 308, 690–699.
Najavits, L. M., Gallop, R. J., & Weiss, R. D. (2006). Seeking Safety therapy for adolescent girls with PTSDand substance use disorder: A randomized controlled trial. The Journal of Behavioral Health Services& Research, 33, 453–463.
Najavits, L. M., Hamilton, N., Miller, N., Doherty, J., Welsh, T., & Vargo, M. Peer-led Seeking Safety:Results of a pilot outcome study with relevance to public health. Manuscript submitted for publication.
Najavits, L. M., & Johnson, K. M. Pilot study of Creating Change, a new past-focused model for PTSDand substance abuse. Manuscript submitted for publication.
Najavits, L. M., Schmitz, M., Gotthardt, S., & Weiss, R. D. (2005). Seeking Safety plus Exposure Therapy:An outcome study on dual diagnosis men. Journal of Psychoactive Drugs, 37, 425–435.
Najavits, L. M., Smylie, D., Johnson, K., Lung, J., Gallop, R., & Classen, C. (in press). Seeking Safetytherapy for pathological gambling and PTSD: A pilot outcome study. Journal of Psychoactive Drugs.
Najavits, L. M., Weiss, R. D., Shaw, S. R., & Muenz, L. R. (1998). “Seeking Safety”: Outcome of anew cognitive-behavioral psychotherapy for women with posttraumatic stress disorder and substancedependence. Journal of Traumatic Stress, 11, 437–456.
Norman, S. B., Wilkins, K. C., Tapert, S. F., Lang, A. J., & Najavits, L. M. (2010). A pilot study of seekingsafety therapy with OEF/OIF veterans. Journal of Psychoactive Drugs, 42, 83–87.
Patitz, B., & Najavits, L. M. Seeking Safety for women with PTSD and substance use disorder: An outcomestudy. Manuscript submitted for publication.
Searcy, V., & Lipps, A. (2012). The Effectiveness of Seeking Safety on reducing PTSD symptoms in clientsreceiving substance dependence treatment. Alcoholism Treatment Quarterly, 30, 238.
Toussaint, D. W., VanDeMark, N. R., Bornemann, A., & Graeber, C. J. (2007). Modifications to the TraumaRecovery and Empowerment Model (TREM) for substance-abusing women with histories of violence:Outcomes and lessons learned at a Colorado Substance Abuse Treatment Center. Journal of CommunityPsychology, 35, 879–894.
Triffleman, E. (2000). Gender differences in a controlled pilot study of psychosocial treatments in substancedependent patients with post-traumatic stress disorder: Design considerations and outcomes. AlcoholismTreatment Quarterly, 18, 113–126.
Wolff, N., Frueh, B. C., Shi, J., & Schumann, B. E. (2012). Effectiveness of cognitive-behavioral traumatreatment for incarcerated women with mental illnesses and substance abuse disorders. Journal of AnxietyDisorders, 26, 703–710.
Young, M. S., Hills, H. A., Rugs, D., Peters, R., Moore, K., Woods-Brown, L., & Pape, L. (2004, July).Integrating Seeking Safety into substance abuse treatment programs. Paper presented at the 112th annualmeeting of the American Psychological Association, Honolulu, HI.
Zlotnick, C., Johnson, J., & Najavits, L. M. (2009). Randomized controlled pilot study of cognitive-behavioral therapy in a sample of incarcerated women with substance use disorder and PTSD. BehaviorTherapy, 40, 325–336.
Zlotnick, C., Najavits, L. M., & Rohsenow, D. J. (2003). A cognitive-behavioral treatment for incarceratedwomen with substance use disorder and posttraumatic stress disorder: Findings from a pilot study.Journal of Substance Abuse Treatment, 25, 99–105.
446 Journal of Clinical Psychology: In Session, May 2013
App
endi
x
Tab
le1
Des
crip
tion
ofS
tudi
es
(b)
Stud
ytr
eatm
ent:
mod
alit
y,do
sage
,tot
alho
urs
(d)
Com
plex
sam
ple
(a)
Mod
el/
Stud
yty
pe/
(and
ince
ntiv
esfo
r(s
ever
e,ch
roni
c,hi
ghly
Stud
yau
thor
atte
ndin
gse
ssio
ns,i
fan
y)(c
)Sa
mpl
eaco
mor
bid,
etc.
)(e
)E
xclu
sion
sfr
omst
udyb
(1)
See
king
Saf
ety
Pilo
tN
ajav
its
etal
.,19
98
Ope
ngr
oup
24se
ssio
ns×
1.5
hour
s.=
36ho
urs
in3
mon
ths.
27ou
tpat
ient
wom
enw
ith
curr
ent
PT
SD+
curr
ent
subs
tanc
ede
pend
ence
(plu
sha
dto
beac
tive
subs
tanc
eus
erin
prio
r30
days
);12
%m
inor
ity.
Yes
Seve
reon
PT
SD,S
UD
,soc
ial
func
tion
ing,
child
hood
trau
ma.
Mos
tun
empl
oyed
,wit
hA
xis
IIdi
sord
ers.
All
subs
tanc
ede
pend
ent,
mos
tdr
ugde
pend
ent.
Min
imal
His
tory
ofsc
hizo
phre
nia,
orga
nic
men
tal
diso
rder
;cur
rent
lyon
met
hado
nem
aint
enan
ceor
man
date
dto
trea
tmen
t.
(2)
See
king
Saf
ety
Pilo
tZ
lotn
ick
etal
.,20
03
Ope
ngr
oup
25se
ssio
ns×
1.5
hour
s.=
37.5
hour
sin
3m
onth
s).
17in
carc
erat
edw
omen
wit
hcu
rren
tP
TSD
,and
subs
tanc
ede
pend
ence
30da
yspr
ior
topr
ison
;33%
min
orit
y.
Yes
Maj
orit
yw
ere
repe
atof
fend
ers;
allh
adsu
bsta
nce
depe
nden
ce,
prim
arily
coca
ine;
mos
tne
ver
grad
uate
dhi
ghsc
hool
;all
had
child
hood
trau
ma,
repe
ated
trau
ma,
maj
orit
yph
ysic
alan
dse
xual
abus
e.
Min
imal
Act
ivel
yps
ycho
tic,
diag
nose
dor
gani
cbr
ain
impa
irm
ent.
(3)
See
king
Saf
ety
Pilo
tY
oung
etal
.,20
03
Gro
up(o
pen
atco
mm
unit
ysi
tes;
clos
edat
jail
site
s).
Com
mun
ity
sett
ings
wer
e25
sess
ion
×1.
5ho
urs
in6
mon
ths;
jail
was
25se
ssio
ns×
1.5
hour
sin
6w
eeks
=37
.5ho
urs.
220
wom
enin
SU
Dtr
eatm
ent,
wit
hva
stm
ajor
ity
havi
ngex
peri
ence
dtr
aum
a;53
%m
inor
ity.
Yes
Pri
mar
ilyun
mar
ried
mot
hers
,35
%w
ith
pare
ntal
righ
tste
rmin
ated
byle
gals
yste
m,d
uepr
imar
ilyto
SUD
;69%
had
prob
lem
sw
ith
mul
tipl
esu
bsta
nces
,an
dsu
bsta
ntia
lper
cent
age
used
subs
tanc
e(s)
daily
;77%
had
prio
rSU
Dtr
eatm
ent;
35%
had
maj
orde
pres
sion
,19%
bipo
lar
Ior
II.
Unc
lear
/Non
eE
xclu
sion
ary
crit
eria
not
repo
rted
.
Review of Treatments 447
Tab
le1
Con
tinu
ed
(b)
Stud
ytr
eatm
ent:
mod
alit
y,do
sage
,tot
alho
urs
(d)
Com
plex
sam
ple
(a)
Mod
el/
Stud
yty
pe/
(and
ince
ntiv
esfo
r(s
ever
e,ch
roni
c,hi
ghly
Stud
yau
thor
atte
ndin
gse
ssio
ns,i
fan
y)(c
)Sa
mpl
eaco
mor
bid,
etc.
)(e
)E
xclu
sion
sfr
omst
udyb
(4)
See
king
Saf
ety
Pilo
tC
ook
etal
.,20
06
Gro
up25
sess
ions
;len
gth
and
tim
ing
not
spec
ified
;ass
ume
25ho
urs.
25m
ean
and
wom
enve
tera
nsw
ith
curr
ent?
PT
SDan
dSU
Dat
Vet
eran
sA
ffai
rs(V
A)
subs
tanc
eab
use
outp
atie
ntcl
inic
;eth
nici
tyno
tre
port
ed.
Yes
(alc
ohol
,coc
aine
,and
hero
inus
edi
sord
ers;
olde
rve
tera
nco
hort
,mea
nag
eof
50).
Unc
lear
/Non
eE
xclu
sion
ary
crit
eria
not
repo
rted
.
(5)
See
king
Saf
ety
Pilo
tP
atit
zet
al.,
unde
rre
view
Clo
sed
grou
p25
sess
ions
×2
hour
s=
37.5
hour
sin
12w
eeks
.
24ou
tpat
ient
rura
lwom
enw
ith
SUD
(ver
ified
byA
SIpl
usin
take
hist
ory)
and
trau
ma
sym
ptom
s(v
erifi
edby
the
TSI
);0%
min
orit
y.
Yes
Rur
al,l
ow-i
ncom
e,al
lhad
com
plex
trau
ma,
unab
leto
succ
eed
inSU
Dre
cove
ryus
ing
12-s
tep
orot
her
addi
ctio
nm
odel
s,us
edva
riou
ssu
bsta
nces
(alc
ohol
,met
ham
phet
amin
em
ost
com
mon
).
Min
imal
Act
ive
psyc
hoti
csy
mpt
oms,
e.g.
,del
usio
ns,
hallu
cina
tion
s.
(6)
See
king
Saf
ety
Pilo
tD
aous
tet
al.,
2011
Ope
ngr
oup
28se
ssio
nsus
ing
Fre
nch
tran
slat
ion
ofSS
×3
hour
s=
84ho
urs.
18m
enan
dw
omen
hosp
ital
outp
atie
nts
wit
hcu
rren
tP
TSD
and
curr
ent
SUD
;1%
min
orit
y.
Yes
Pri
mar
ilyph
ysic
al,s
exua
l,an
d/or
child
hood
trau
ma
(lat
ter
78%
);22
%in
pris
onin
thei
rlif
etim
e.P
rim
ary
subs
tanc
es:a
lcoh
ol,o
piat
es,
cann
abis
,coc
aine
.
Min
imal
Psy
chos
is,n
ope
rman
ent
resi
denc
y,or
bein
gac
tive
lyin
volv
edin
crim
inal
acti
viti
es.
(7)
See
king
Saf
ety
Pilo
tW
olff
etal
.,20
12
Clo
sed
grou
p28
sess
ions
×1.
5ho
urs=
42ho
urs
in14
wee
ks(u
sed
23of
the
25SS
topi
cs).
74in
carc
erat
edw
omen
wit
hm
enta
lilln
ess
inad
diti
onto
PT
SD(8
8%fu
ll,12
%su
bthr
esho
ld);
SUD
;64%
min
orit
y.
Yes
Mos
tw
ere
viol
ent
offe
nder
sw
ith
seri
ous
men
tali
llnes
s,in
clud
ing
bipo
lar/
psyc
hoti
c;ch
ildse
xual
abus
e;av
erag
eof
15lif
est
ress
ors;
inm
inim
um,
med
ium
,or
max
imum
secu
rity
.
Unc
lear
/Non
eE
xclu
sion
ary
crit
eria
not
repo
rted
.
448 Journal of Clinical Psychology: In Session, May 2013
Tab
le1
Con
tinu
ed
(b)
Stud
ytr
eatm
ent:
mod
alit
y,do
sage
,tot
alho
urs
(d)
Com
plex
sam
ple
(a)
Mod
el/
Stud
yty
pe/
(and
ince
ntiv
esfo
r(s
ever
e,ch
roni
c,hi
ghly
Stud
yau
thor
atte
ndin
gse
ssio
ns,i
fan
y)(c
)Sa
mpl
eaco
mor
bid,
etc.
)(e
)E
xclu
sion
sfr
omst
udyb
(8)
See
king
Saf
ety
Pilo
tN
ajav
its
etal
.,20
13
Indi
vidu
al25
wee
kly
sess
ions
×50
min
utes
=25
hour
sin
6m
onth
s.
7m
enan
dw
omen
outp
atie
nts
wit
hcu
rren
tP
TSD
and
curr
ent
path
olog
ical
gam
blin
gdi
sord
er;
29%
min
orit
y.
Yes
Chi
ldho
odon
set
ofP
TSD
;al
lexp
erie
nced
phys
ical
,sex
ual,
and
othe
rtr
aum
aty
pes;
low
-inc
ome,
chro
nic
and
seve
re.
Min
imal
His
tory
ofdi
agno
sed
and
veri
fied
bipo
lar
1di
sord
eror
psyc
hoti
cdi
sord
er;
inst
itut
iona
lized
<3
wee
ksin
prio
r3
mon
ths
(“ou
tpat
ient
”).
(9)
Peer
-led
See
king
Saf
ety
Pilo
tN
ajav
its
etal
.und
erre
view
Clo
sed
grou
p25
sess
ions
×1
hour
=25
hour
s.18
wom
enin
resi
dent
ialS
UD
prog
ram
for
mot
hers
and
thei
rch
ildre
n;22
%m
inor
ity.
Yes
All
wit
hm
ulti
ple
trau
mas
,pr
edom
inan
tly
child
hood
repe
ated
phys
ical
and/
orse
xual
abus
e;su
bsta
nce
depe
nden
ce(o
nin
take
toth
efa
cilit
y);a
ndlo
w-
inco
me.
Maj
orH
adto
bein
the
resi
dent
ialp
rogr
amfo
r90
days
,an
dpl
anne
dto
rem
ain
for
atle
ast
6m
onth
s(t
oco
mpl
ete
the
proj
ect)
.
(10)
Part
ial-
dose
(40%
)S
eeki
ngS
afet
yP
ilot
Nor
man
etal
.201
0
Ope
ngr
oup
10w
eekl
yse
ssio
ns×
1.5
hour
s=15
hour
sin
10w
eeks
.
9m
enve
tera
nsw
ith
curr
ent
PT
SDan
dSU
Dat
aV
Aho
spit
al;3
6%m
inor
ity.
Yes
Seve
reon
both
PT
SDan
dde
pres
sion
mea
sure
sat
base
line.
Unc
lear
/Non
eE
xclu
sion
ary
crit
eria
not
repo
rted
.
(11)
Part
ial-
dose
(32%
)S
eeki
ngS
afet
yP
ilot
Sear
cy&
Lip
ps,2
012
Ope
ngr
oup
Tw
ice
per
wee
k×
1ho
urdu
ring
28-d
ayst
ay=
8ho
urs.
40m
enan
dw
omen
in28
-day
SU
Dre
side
ntia
lpro
gram
wit
hsu
bsta
nce
depe
nden
cean
dP
TSD
sym
ptom
s;10
%m
inor
ity.
Yes
Maj
orit
yun
empl
oyed
,wit
hpa
stor
pres
ent
lega
lpro
blem
s,22
%at
tem
pted
suic
ide
inpa
st;
both
drug
san
dal
coho
lpr
omin
ent
(pre
dom
inan
tly
stim
ulan
ts,a
lcoh
ol,o
piat
es).
Non
eA
llcl
ient
sin
the
prog
ram
wer
eof
fere
dth
eop
tion
topa
rtic
ipat
e;no
excl
usio
nary
crit
eria
.
Review of Treatments 449
Tab
le1
Con
tinu
ed
(b)
Stud
ytr
eatm
ent:
mod
alit
y,do
sage
,tot
alho
urs
(d)
Com
plex
sam
ple
(a)
Mod
el/
Stud
yty
pe/
(and
ince
ntiv
esfo
r(s
ever
e,ch
roni
c,hi
ghly
Stud
yau
thor
atte
ndin
gse
ssio
ns,i
fan
y)(c
)Sa
mpl
eaco
mor
bid,
etc.
)(e
)E
xclu
sion
sfr
omst
udyb
(12)
Unc
lear
dose
See
king
Saf
ety
Pilo
tB
ento
net
al.,
2011
,201
2
Clo
sed
grou
pW
eekl
yse
ssio
nsof
1.5
hour
sov
er3
mon
ths
(but
noat
tend
ance
data
repo
rted
,nor
whi
chto
pics
from
SS)=
19.5
hour
s(a
ssum
e13
wee
ks).
20ou
tpat
ient
wom
enin
aS
UD
clin
ic,w
ith
curr
ent
PT
SDan
dcu
rren
tSU
D,a
llof
who
mha
dal
read
yco
mpl
eted
the
clin
ic’s
8-w
eek
SUD
IOP
(up
tosi
xm
onth
spr
ior)
;50%
had
PT
SDat
base
line;
30%
min
orit
y.
Yes
Maj
orit
yun
empl
oyed
,and
“hig
hpr
opor
tion
ofch
ildho
odse
xual
abus
e”.
Min
imal
His
tory
ofsc
hizo
phre
nia,
acti
vebi
pola
rdi
sord
er,i
mpe
ndin
gin
carc
erat
ion,
orlif
e-th
reat
enin
g/un
stab
lem
edic
alill
ness
.
(13)
See
king
Saf
ety
Con
trol
led
tria
l(o
nesi
teof
WC
DV
Scst
udy)
Gat
zet
al.,
2007
Gro
up31
sess
ions
×1.
5ho
urs=
46.5
hour
s;se
ssio
nsw
ere
held
twic
epe
rw
eek.
313
wom
enin
resi
dent
ial
trea
tmen
twit
hSU
Dan
dco
-occ
urri
ngm
enta
lhea
lth
diso
rder
(bot
hin
past
5ye
ars,
and
atle
ast
one
inpa
st30
days
),ex
peri
ence
dph
ysic
alor
sexu
alab
use;
had
atle
ast
two
prio
rtr
eatm
ent
epis
odes
.Sa
mpl
ew
asn
=13
6in
SSvs
.n
=17
7co
mpa
riso
nw
omen
;all
rece
ived
trau
ma-
info
rmed
,in
tegr
ated
SUD
/men
talh
ealt
hse
rvic
es;6
3%m
inor
ity.
Yes
Inad
diti
onto
co-o
ccur
ring
SUD
/psy
chia
tric
diso
rder
s,m
ost
had
expe
rien
ced
child
abus
e,be
enho
mel
ess,
serv
edja
ilti
me,
suff
ered
inte
rper
sona
lab
use
inpa
st6
mon
ths;
SUD
prim
arily
drug
sra
ther
than
alco
hol
(met
ham
phet
amin
eco
mm
on).
Unc
lear
/Non
eE
xclu
sion
ary
crit
eria
not
repo
rted
.
450 Journal of Clinical Psychology: In Session, May 2013T
able
1C
onti
nued
(b)
Stud
ytr
eatm
ent:
mod
alit
y,do
sage
,tot
alho
urs
(d)
Com
plex
sam
ple
(a)
Mod
el/
Stud
yty
pe/
(and
ince
ntiv
esfo
r(s
ever
e,ch
roni
c,hi
ghly
Stud
yau
thor
atte
ndin
gse
ssio
ns,i
fan
y)(c
)Sa
mpl
eaco
mor
bid,
etc.
)(e
)E
xclu
sion
sfr
omst
udyb
(14)
See
king
Saf
ety
(del
iver
edby
case
man
ager
s)C
ontr
olle
dtr
ial
Des
aiet
al.,
2008
,200
9
Gro
upor
indi
vidu
al(c
linic
ians
coul
dco
nduc
tei
ther
mod
alit
y)25
wee
kly
sess
ions
over
6m
onth
s;as
sum
e1
hour
per
sess
ion
(len
gth
not
spec
ified
)=
25ho
urs.
450
hom
eles
sw
omen
vete
rans
wit
had
dict
ion
and/
orps
ychi
atri
cpr
oble
ms,
all
rece
ivin
gin
tens
ive
case
man
agem
ent
(IC
M).
Tw
oco
hort
s:n
=35
9in
ICM
,fo
llow
edby
91in
SSpl
usIC
M;
65%
min
orit
y.
Yes
Hom
eles
s,pl
ushi
ghlif
etim
etr
aum
ara
tes
(ave
rage
of9)
;68%
had
been
rape
d;35
%re
port
edtr
aum
are
late
dto
pros
titu
tion
.
Non
e/M
inim
al“U
nsta
ble
topa
rtic
ipat
e”as
deci
ded
byth
est
udy
inve
stig
ator
.
(15)
See
king
Saf
ety
Con
trol
led
tria
lL
ynch
etal
.,20
12
Ope
ngr
oup
24se
ssio
ns×
2ho
urs=
48ho
urs
in12
wee
ks.
114
inca
rcer
ated
wom
enw
ith
mod
erat
eor
high
erP
TSD
sym
ptom
s(≥
30on
PC
L),
hist
ory
ofSU
D;1
6%m
inor
ity.
Yes
Mos
tre
peat
offe
nder
s,vi
ctim
sof
mul
tipl
evi
olen
tcr
imes
and
sexu
alas
saul
t;m
ajor
ity
had
seve
re,≥
50P
CL
sym
ptom
s,an
dde
pres
sion
;pr
imar
ydr
ugw
asm
etha
mph
etam
ine.
Unc
lear
/Non
eE
xclu
sion
ary
crit
eria
not
repo
rted
.
(16)
See
king
Saf
ety
RC
T(h
ybri
d)H
ien,
Coh
enet
al.,
2004
Indi
vidu
al12
twic
ew
eekl
yse
ssio
ns×
1ho
ur=
24ho
urs
in3
mon
ths.
107
com
mun
ity
outp
atie
ntw
omen
wit
hcu
rren
tP
TSD
(88%
full;
12%
subt
hres
hold
)+
curr
ent
SUD
;had
tobe
acti
vesu
bsta
nce
user
inpr
ior
30da
ys);
75.6
%m
inor
ity.
Yes
Seve
reon
PT
SD,m
ost
wit
hch
ildho
odtr
aum
a;al
lwit
hsu
bsta
nce
depe
nden
ce,m
ost
wit
hdr
ugde
pend
ence
;mos
tun
empl
oyed
wit
hlo
wso
cial
func
tion
ing.
Min
imal
Act
ivel
yps
ycho
tic,
orga
nic
men
tald
isor
der;
sign
ifica
ntsu
icid
alor
hom
icid
alin
tent
.
(17)
See
king
Saf
ety
RC
TN
ajav
its
etal
.,20
06
Indi
vidu
al25
sess
ions
of50
min
utes
=21
hour
sin
3m
onth
s(t
wic
e-w
eekl
yse
ssio
ns).
33ou
tpat
ient
adol
esce
nts
wit
hcu
rren
tP
TSD
and
curr
ent
SUD
(94%
wit
hsu
bsta
nce
depe
nden
ce),
plus
acti
vesu
bsta
nce
use
inpr
ior
60da
ys;
n=
18in
SSpl
usT
AU
vers
usn
=15
TA
Uon
ly;2
1%m
inor
ity.
Yes
Chi
ldho
odP
TSD
;mos
tha
dse
xual
and
phys
ical
abus
e;m
ost
had
drug
rath
erth
anal
coho
ldep
ende
nce.
Min
imal
His
tory
ofbi
pola
rI
diso
rder
(man
ia),
psyc
hoti
cdi
sord
er;c
urre
ntly
man
date
dto
trea
tmen
t.
Review of Treatments 451
Tab
le1
Con
tinu
ed
(b)
Stud
ytr
eatm
ent:
mod
alit
y,do
sage
,tot
alho
urs
(d)
Com
plex
sam
ple
(a)
Mod
el/
Stud
yty
pe/
(and
ince
ntiv
esfo
r(s
ever
e,ch
roni
c,hi
ghly
Stud
yau
thor
atte
ndin
gse
ssio
ns,i
fan
y)(c
)Sa
mpl
eaco
mor
bid,
etc.
)(e
)E
xclu
sion
sfr
omst
udyb
(18)
See
king
Saf
ety
RC
TB
oden
etal
.,20
12
Ope
ngr
oup
24se
ssio
nsin
3m
onth
s;se
ssio
nle
ngth
uncl
ear,
assu
me
1.15
hour
s=
30ho
urs.
117
men
outp
atie
ntve
tera
nsw
ith
curr
ent
SUD
and
curr
ent
PT
SD(a
llfu
llP
TSD
,exc
ept
n=
9su
bthr
esho
ld);
81%
min
orit
y.
Yes
Maj
orit
yun
empl
oyed
,wit
hbo
thdr
ugan
dal
coho
lpr
oble
ms,
olde
rve
tera
nco
hort
(mea
nag
eov
er50
),40
%ho
mel
ess;
“tre
atm
ent-
resi
stan
t”.
Min
imal
Acu
teps
ycho
sis,
man
ia,d
emen
tia,
orsu
icid
alin
tent
.
(19)
Part
ial-
dose
(%va
ried
)S
eeki
ngS
afet
yR
CT
Zlo
tnic
ket
al.,
2009
Ope
ngr
oup
90m
inut
esw
hile
inpr
ison
,va
ryin
gdo
sage
;ave
rage
was
15.6
sess
ions
=23
.4ho
urs
tota
lin
6–8
wee
ks.
49in
carc
erat
edw
omen
wit
hcu
rren
tP
TSD
(ful
l,83
.5%
,or
subt
hres
hold
,16.
5%)
and
curr
ent
SUD
(88%
depe
nden
ce);
n=
27in
SSpl
usT
AU
vers
us22
inT
AU
alon
e.T
AU
was
man
dato
ryin
the
pris
onan
dhi
gh-d
ose
(180
–240
trea
tmen
thou
rs);
53%
min
orit
y.
Yes
Rep
eat
offe
nder
s;ch
ildho
odP
TSD
,maj
orit
yw
ith
sexu
al/p
hysi
calr
epea
ted
trau
ma,
child
hood
SUD
,ch
roni
c,bo
thal
coho
land
drug
depe
nden
ce.
Min
imal
Act
ivel
yps
ycho
tic
atti
me
ofre
crui
tmen
t;or
gani
cbr
ain
impa
irm
ent
diag
nosi
s.
(20)
Part
ial-
dose
(24%
)S
eeki
ngS
afet
yR
CT
Ghe
eet
al.,
2009
Gro
up6
sess
ions
;eac
hse
ssio
n1.
5ho
urs=
9ho
urs
(hel
dov
er3–
4w
eeks
).
104
wom
enin
resi
dent
ialS
UD
trea
tmen
t(51
SSpl
usT
AU
vs.
52T
AU
);49
%m
inor
ity.
Yes
“His
tori
esof
inte
rgen
erat
iona
lsub
stan
ceab
use,
untr
eate
dhi
stor
ies
ofse
xual
abus
e,se
vere
phys
ical
abus
e,or
conc
omit
ant
men
tal
heal
thne
eds;
”98
%of
stud
ysa
mpl
eun
empl
oyed
;mos
tlo
win
com
e;m
any
low
educ
atio
n.
Min
imal
No
acti
veps
ycho
sis
orse
vere
med
ical
(phy
sica
l)co
ndit
ion.
452 Journal of Clinical Psychology: In Session, May 2013
Tab
le1
Con
tinu
ed
(b)
Stud
ytr
eatm
ent:
mod
alit
y,do
sage
,tot
alho
urs
(d)
Com
plex
sam
ple
(a)
Mod
el/
Stud
yty
pe/
(and
ince
ntiv
esfo
r(s
ever
e,ch
roni
c,hi
ghly
Stud
yau
thor
atte
ndin
gse
ssio
ns,i
fan
y)(c
)Sa
mpl
eaco
mor
bid,
etc.
)(e
)E
xclu
sion
sfr
omst
udyb
(21)
Part
ial-
dose
(48%
)S
eeki
ngS
afet
yR
CT
Hie
net
al.,
2009
Ope
ngr
oup
6tw
ice
wee
kly
sess
ions
×1.
5ho
urs=
18ho
urs
in1.
5m
onth
s.
353
outp
atie
ntw
omen
wit
hcu
rren
tP
TSD
(80%
full;
20%
subt
hres
hold
)+
curr
ent
abus
eor
depe
nden
ce(p
lus
coul
dha
vesu
bthr
esho
ldP
TSD
(DSM
-IV
Cri
teri
onA
,B,F
and
eith
erC
orD
);ha
dto
beac
tive
subs
tanc
eus
erin
prio
r6
mon
ths)
;54.
4%m
inor
ity.
Yes
Seve
reon
PT
SD,S
UD
,so
cial
func
tion
ing,
child
hood
trau
ma.
Mos
tun
empl
oyed
.All
subs
tanc
ede
pend
ent,
mos
twit
hdr
ugde
pend
ence
.
Min
imal
Act
ivel
yps
ycho
tic,
orga
nic
men
tald
isor
der;
sign
ifica
ntsu
icid
alor
hom
icid
alin
tent
,lit
igat
ion
reP
TSD
.
(22)
Hel
ping
Wom
enR
ecov
er(H
WR
)pl
usB
eyon
dT
raum
a(B
T),
calle
dW
omen
’sIn
tegr
ated
Tre
atm
ent(
WIT
)P
ilot
Cov
ingt
onet
al.,
2008
Gro
uppl
usvi
deo
Unc
lear
:ass
ume
atle
ast
28ho
urs
(BT
and
HW
Rto
tal
28se
ssio
ns),
but
nolis
ting
ofdo
se,d
urat
ion,
tim
ing,
leng
thof
sess
ion,
whe
ther
grou
psw
ere
open
orcl
osed
,att
enda
nce
atW
IT,o
rho
wvi
deo
was
used
.T
here
side
ntia
lSU
Dpr
ogra
mis
liste
das
12m
onth
s.
202
wom
enin
resi
dent
ialS
UD
trea
tmen
twho
had
alre
ady
com
plet
ed45
days
inth
ere
side
ntia
lSU
Dpr
ogra
m(“
stab
iliza
tion
”);5
9%m
inor
ity.
Yes
Maj
orit
yha
dm
ulti
ple
trau
mas
,cri
min
alhi
stor
y(e
.g.,
prio
rar
rest
),la
cked
stab
leho
usin
gpr
ior
topr
ison
,had
met
ham
phet
amin
eas
thei
rpr
imar
ydr
ugpr
oble
m;h
adpr
oble
ms
wit
h2
orm
ore
subs
tanc
es;a
nav
erag
eof
10ye
ars
subs
tanc
epr
oble
ms;
28%
had
atte
mpt
edsu
icid
e.
Maj
orC
ompl
etio
nof
45da
ysre
side
ntia
lSU
Dpr
ogra
mst
abili
zati
on.O
ther
than
that
,no
stat
emen
tof
incl
usio
nary
/ex
clus
iona
rycr
iter
ia.
Hal
fth
esa
mpl
em
anda
ted
totr
eatm
ent.
Review of Treatments 453
Tab
le1
Con
tinu
ed
(b)
Stud
ytr
eatm
ent:
mod
alit
y,do
sage
,tot
alho
urs
(d)
Com
plex
sam
ple
(a)
Mod
el/
Stud
yty
pe/
(and
ince
ntiv
esfo
r(s
ever
e,ch
roni
c,hi
ghly
Stud
yau
thor
atte
ndin
gse
ssio
ns,i
fan
y)(c
)Sa
mpl
eaco
mor
bid,
etc.
)(e
)E
xclu
sion
sfr
omst
udyb
(23)
Hel
ping
Wom
enR
ecov
er(H
WR
)pl
usB
eyon
dT
raum
a(B
T),
calle
dG
ende
rR
espo
nsiv
eT
reat
men
t(G
RT
)R
CT
Mes
sina
etal
.,20
10
Unc
lear
ifgr
oup,
indi
vidu
alor
both
(app
ears
tobe
latt
er).
Dos
age
“app
roxi
mat
ely”
20ho
urs
per
wee
kfo
r“a
ppro
xim
atel
y”6
mon
ths”
=52
0ho
urs
[sam
eas
for
TA
U].
Len
gth
ofse
ssio
nsan
ddo
seof
HW
Rve
rsus
BT
(the
yar
ese
para
tem
anua
ls)
not
repo
rted
;att
enda
nce
data
not
repo
rted
for
GR
Tor
TA
U.
115
wom
enm
anda
ted
topr
ison
-bas
edS
UD
trea
tmen
t,w
hich
was
eith
erG
RT
orSU
Dth
erap
euti
cco
mm
unit
y;60
inG
RT
vers
us55
inT
AU
.At
base
line,
95%
ofth
efu
llsa
mpl
eha
dSU
D;2
6%ha
dP
TSD
;52%
min
orit
y.
Yes
Maj
orit
yun
empl
oyed
prio
rto
pris
on,h
adm
etha
mph
etam
ine
aspr
imar
ydr
ugpr
oble
mpr
ior
topr
ison
,ha
dhi
stor
ies
ofse
xual
and
phys
ical
abus
e,an
dha
dbe
enin
carc
erat
edan
aver
age
of4.
7ye
ars
lifet
ime.
Min
imal
/uns
peci
fied
Mem
bers
hip
inpr
ison
gang
;se
greg
ated
for
viol
ence
orw
eapo
nsch
arge
sin
past
year
;or
inpr
ison
due
tofe
lony
orim
mig
rati
on(a
llel
igib
ility
wit
hin
the
pris
onpr
ogam
);bu
tno
excl
usio
nary
crit
eria
repo
rted
for
the
stud
yit
self.
Clie
nts
wer
em
anda
ted
toG
RT
.
(24)
Inte
grat
edC
BT
for
PT
SD
and
SU
D(I
CB
T)
plus
SU
Din
tens
ive
outp
atie
ntpr
ogra
mP
ilot
McG
over
net
al.,
2009
Indi
vidu
alU
ncle
ardo
sage
:met
hods
sect
ion
stat
es8–
12se
ssio
nsar
ene
eded
;Fig
ure
2in
dica
tes
upto
14se
ssio
nsco
nduc
ted.
Len
gth
and
tim
ing
ofse
ssio
nsno
tst
ated
.Ass
ume
14se
ssio
n×
1ho
ur=
14ho
urs.
11m
enan
dw
omen
inS
UD
inte
nsiv
eou
tpat
ient
prog
ram
,w
ith
curr
ent
PT
SD;0
%m
inor
ity.
Yes
Maj
orit
yha
dch
ildse
xual
assa
ult;
seve
reP
TSD
(bas
edon
init
ialC
AP
Ssc
ore)
.
Unc
lear
/Non
eE
xclu
sion
ary
crit
eria
not
repo
rted
.
454 Journal of Clinical Psychology: In Session, May 2013
Tab
le1
Con
tinu
ed
(b)
Stud
ytr
eatm
ent:
mod
alit
y,do
sage
,tot
alho
urs
(d)
Com
plex
sam
ple
(a)
Mod
el/
Stud
yty
pe/
(and
ince
ntiv
esfo
r(s
ever
e,ch
roni
c,hi
ghly
Stud
yau
thor
atte
ndin
gse
ssio
ns,i
fan
y)(c
)Sa
mpl
eaco
mor
bid,
etc.
)(e
)E
xclu
sion
sfr
omst
udyb
(25)
Inte
grat
edC
BT
for
PT
SD
and
SU
D(I
CB
T)
plus
SU
DIO
Por
met
hado
nem
aint
enan
cetr
eatm
ent
RC
TM
cGov
ern
etal
.,20
11
Indi
vidu
alIC
BT
was
8m
odul
esde
liver
edw
eekl
yov
er“a
ppro
xim
atel
y”12
-14
sess
ions
(pg.
212)
but
uncl
ear
asla
ter
isst
ated
as8-
12w
eeks
ofw
eekl
yse
ssio
ns(p
g.21
4);s
essi
ons
wer
e50
min
utes
=11
.67
hour
s[a
ssum
ing
14se
ssio
ns×
50m
inut
es].
IAC
(com
pari
son
cond
itio
n)ap
pear
sto
belo
wer
dose
:“10
-12
wee
kly
sess
ions
”de
liver
edov
er8–
12w
eeks
(pg.
214)
=10
sess
ions
[ass
umin
g12
50-m
inut
ese
ssio
ns].
53m
enan
dw
omen
inS
UD
inte
nsiv
eou
tpat
ient
orm
etha
done
mai
nten
ance
trea
tmen
t,w
ith
curr
ent
PT
SD(a
ndC
AP
Ssc
ore
≥44
);32
inIC
BT
vers
us21
inIn
divi
dual
Add
icti
onC
ouns
elin
g(I
AC
,am
anua
lized
addi
ctio
n-on
lym
odel
);9%
min
orit
y.
Yes
Maj
orit
yha
dch
ildho
odse
xual
assa
ult;
seve
reP
TSD
(bas
edon
init
ialC
AP
Ssc
ore)
.
Maj
orA
llha
dto
beac
tive
inSU
Din
tens
ive
outp
atie
nttr
eatm
ent
orm
etha
done
mai
nten
ance
;no
acut
eps
ycho
tic
sym
ptom
s;no
suic
ide
atte
mpt
orps
ychi
atri
cho
spit
aliz
atio
nin
past
mon
th(u
nles
sla
tter
dire
ctly
rela
ted
tosu
bsta
nce
into
xica
tion
orde
toxi
ficat
ion
and
curr
entl
yst
able
);an
dm
edic
alan
dle
gal
situ
atio
nsw
ere
stab
le.
Review of Treatments 455
Tab
le1
Con
tinu
ed
(b)
Stud
ytr
eatm
ent:
mod
alit
y,do
sage
,tot
alho
urs
(d)
Com
plex
sam
ple
(a)
Mod
el/
Stud
yty
pe/
(and
ince
ntiv
esfo
r(s
ever
e,ch
roni
c,hi
ghly
Stud
yau
thor
atte
ndin
gse
ssio
ns,i
fan
y)(c
)Sa
mpl
eaco
mor
bid,
etc.
)(e
)E
xclu
sion
sfr
omst
udyb
(26)
Tra
uma
Ada
ptiv
eR
ecov
ery
Gro
upE
duca
tion
and
The
rapy
(TA
RG
ET
)R
CT
Fri
sman
etal
.,20
08
Gro
up8
or9
wee
kly
sess
ions
;len
gth
uncl
ear;
assu
me
1.15
hour
s=
11.2
5ho
urs.
213
outp
atie
ntm
enan
dw
omen
inS
UD
trea
tmen
t,w
hoex
peri
ence
da
trau
ma
(lif
etim
e),
plus
met
eith
er(a
)P
TSD
(b)
DE
SNO
Spl
usat
leas
ton
eor
mor
eA
xis
Idi
sord
ers
or(c
)m
ajor
depr
essi
vedi
sord
er,
dyst
hym
icdi
sord
er,o
rdi
ssoc
iati
vedi
sord
er.A
ssig
ned
toT
AR
GE
T(n
=14
1)or
Tra
uma-
Sens
itiv
eC
are
asU
sual
(TSU
)n
=72
;44%
min
orit
y.
Yes
Low
inco
me,
mos
tun
empl
oyed
,had
expe
rien
ced
hom
eles
snes
s(l
ifet
ime)
,had
been
arre
sted
atso
me
poin
t.
Unc
lear
/Non
eE
xclu
sion
ary
crit
eria
not
repo
rted
.
Smal
linc
enti
ves
rela
ted
toT
AR
GE
T(e
.g.,
keyc
hain
,pen
)ha
nded
out
atth
ree
sess
ions
;an
dcl
inic
ians
peri
odic
ally
brou
ght
refr
eshm
ents
togr
oup.
(27)
Tra
uma
Rec
over
yan
dE
mpo
wer
men
tMod
el(T
RE
M),
mod
ified
and
part
ial-
dose
vers
ion,
plus
Cop
elan
d’s
trau
ma
self
-hel
pbo
okC
ontr
olle
dtr
ial
(one
WC
DV
Sst
udy
site
)c
Tous
sain
tet
al.,
2007
Gro
upan
din
divi
dual
24gr
oup
TR
EM
sess
ions
(16
sess
ions
twic
e/w
eek
for
8w
eeks
;the
n8
sess
ions
/wee
k);
plus
upto
24in
divi
dual
sess
ions
wit
ha
coun
selo
rto
revi
ewth
eT
RE
Mw
orkb
ook
mat
eria
l;le
ngth
ofgr
oup
and
indi
vidu
alse
ssio
nsno
tsp
ecifi
ed.
Ass
umin
g1.
25ho
urpe
rgr
oup
sess
ion
(per
Fal
lot
&H
arri
s,20
00),
and
1ho
urin
divi
dual
sess
ion
tota
l=30
-54
hour
s.
170
wom
enin
resi
dent
ial
trea
tmen
tmee
ting
WC
DV
Scr
iter
ia(s
eest
udy
#14
);ha
dat
leas
ttw
opr
ior
trea
tmen
tep
isod
es.S
ampl
ew
asn
=64
inT
RE
Mvs
.n=
106
com
pari
son
wom
en;a
llw
omen
inth
est
udy
rece
ived
trau
ma-
info
rmed
,in
tegr
ated
SUD
/men
talh
ealt
hse
rvic
es;4
7%m
inor
ity.
Yes
All
wit
hcu
rren
tsu
bsta
nce
depe
nden
ce,a
ndm
othe
rsof
child
ren
unde
rag
e13
;mos
tun
empl
oyed
.All,
per
the
WC
DV
Sst
udy,
had
SUD
and
co-o
ccur
ring
men
talh
ealt
hdi
sord
er,e
xper
ienc
edph
ysic
alor
sexu
alab
use;
and
atle
ast
two
prio
rtr
eatm
ent
epis
odes
.
Unc
lear
/Non
eE
xclu
sion
ary
crit
eria
not
repo
rted
.
456 Journal of Clinical Psychology: In Session, May 2013
Tab
le1
Con
tinu
ed
(b)
Stud
ytr
eatm
ent:
mod
alit
y,do
sage
,tot
alho
urs
(d)
Com
plex
sam
ple
(a)
Mod
el/
Stud
yty
pe/
(and
ince
ntiv
esfo
r(s
ever
e,ch
roni
c,hi
ghly
Stud
yau
thor
atte
ndin
gse
ssio
ns,i
fan
y)(c
)Sa
mpl
eaco
mor
bid,
etc.
)(e
)E
xclu
sion
sfr
omst
udyb
(28)
Tra
uma
Rec
over
yE
mpo
wer
men
tMod
el(T
RE
M)
aspa
rtof
Bos
ton
Con
sort
ium
Mod
el(B
CM
)C
ontr
olle
dtr
ial(
one
WC
DV
Sst
udy
site
)c
Am
aro
etal
.,20
07a,
2007
b
Gro
uppl
usin
divi
dual
case
man
agem
ent
BC
Mgr
oup
is10
1.25
grou
pho
urs
com
pris
ing
5m
anua
lized
mod
ules
:(1)
25T
RE
Mse
ssio
nsm
odifi
edto
incl
ude
3se
ssio
nsfo
rH
IV/A
IDS
prev
enti
on)
[31.
25ho
urs]
;(2)
3se
ssio
nsof
wom
en’s
lead
ersh
iptr
aini
ng[1
5ho
urs]
;(3)
8se
ssio
nsof
econ
omic
succ
ess
inre
cove
ry[1
6ho
urs]
;(4)
10se
ssio
nsof
Pat
hway
sto
Fam
ilyR
euni
ficat
ion
and
Rec
over
y[1
5ho
urs]
;(5)
12se
ssio
nsof
Nur
turi
ngP
rogr
amfo
rF
amili
es[2
4ho
urs]
,plu
san
unsp
ecifi
edam
ount
ofin
divi
dual
case
man
agem
ent.
342
wom
enin
resi
dent
ial,
outp
atie
nt,o
rm
etha
done
prog
ram
;n=
181
wom
enin
BC
Mpl
usT
AU
vers
us16
1w
omen
inT
AU
alon
e.(T
AU
was
wee
kly
grou
pan
d/or
indi
vidu
altr
eatm
ent
last
ing
6-12
mon
ths)
.All
met
WC
DV
Scr
iter
ia(s
eest
udy
#14
);65
.5%
min
orit
y.
Yes
Mos
tw
ith
less
than
high
scho
oled
ucat
ion,
unem
ploy
ed;
allw
ith
SUD
and
co-o
ccur
ring
men
talh
ealt
hdi
sord
er,
expe
rien
ced
phys
ical
orse
xual
abus
e;ha
dat
leas
ttw
opr
ior
trea
tmen
tep
isod
es.
Unc
lear
/Min
imal
Bas
edon
clin
icia
nad
vice
,exc
lude
dw
omen
“in
anes
peci
ally
sens
itiv
est
ate,
that
is,t
hose
who
may
not
have
been
able
togi
vere
ason
able
answ
ers
toth
ein
terv
iew
and
thos
efo
rw
hom
the
inte
rvie
wco
uld
have
trig
gere
dth
ere
expe
rien
ceof
trau
mat
icev
ents
.”
Review of Treatments 457
Tab
le1
Con
tinu
ed
(b)
Stud
ytr
eatm
ent:
mod
alit
y,do
sage
,tot
alho
urs
(d)
Com
plex
sam
ple
(a)
Mod
el/
Stud
yty
pe/
(and
ince
ntiv
esfo
r(s
ever
e,ch
roni
c,hi
ghly
Stud
yau
thor
atte
ndin
gse
ssio
ns,i
fan
y)(c
)Sa
mpl
eaco
mor
bid,
etc.
)(e
)E
xclu
sion
sfr
omst
udyb
(29)
Tra
uma
Rec
over
yan
dE
mpo
wer
men
tMod
el(T
RE
M)
plus
indi
vidu
alin
tegr
ated
trau
ma
serv
ices
.C
ontr
olle
dtr
ial
(one
WC
DV
Sst
udy
site
)c
Fal
lot
etal
.,20
11
Gro
up(o
pen
init
ially
then
clos
ed)p
lus
indi
vidu
altr
aum
ase
rvic
esT
RE
Mgr
oup
was
33w
eekl
yse
ssio
ns×
1.25
hour
s=
41.2
5to
talg
roup
hour
sin
8m
onth
s;2-
3co
-lea
ders
per
grou
p;pl
usin
divi
dual
sess
ions
ofun
spec
ified
dura
tion
and
freq
uenc
y(i
nteg
rate
dtr
aum
ase
rvic
eco
unse
ling)
.
251
wom
enre
crui
ted
from
com
mun
ity
agen
cies
;un
spec
ified
asto
leve
lof
care
(i.e
.,un
clea
rif
outp
atie
nt,d
aypr
ogra
m,o
rre
side
ntia
l);1
53in
TR
EM
+T
AU
+in
tegr
ated
trau
ma
serv
ices
vers
us98
inT
AU
[sam
ein
clus
ion
crit
eria
asst
udy
#28
];85
%m
inor
ity.
Yes
Mos
tun
empl
oyed
,wit
hhi
stor
yof
both
child
and
adul
tse
xual
and
phys
ical
abus
e;av
erag
eof
5pr
ior
hosp
ital
izat
ions
.
Unc
lear
/Non
eE
xclu
sion
ary
crit
eria
not
repo
rted
.
(30)
Con
curr
entT
reat
men
tof
PT
SD
and
Coc
aine
Dep
ende
nce
(CT
PC
D)j
Pre
sent
-an
dpa
st-f
ocus
edP
ilot
Bra
dyet
al.,
2001
Indi
vidu
al16
sess
ions
×1.
5ho
urs=
24ho
urs,
cond
ucte
dat
vary
ing
pace
(1–2
sess
ions
per
wee
k).
39m
enan
dw
omen
outp
atie
nts
wit
hcu
rren
tP
TSD
and
curr
ent
coca
ine
depe
nden
ce,p
lus
had
toat
tend
atle
ast
1se
ssio
nof
the
stud
yth
erap
y;51
%m
inor
ity.
Yes
All
had
subs
tanc
ede
pend
ence
;maj
orit
yha
dco
-occ
urri
ngaf
fect
ive
diso
rder
,an
dha
dex
peri
ence
dra
pe.
Mod
erat
eSu
icid
alor
hom
icid
alid
eati
on,p
sych
osis
,dis
soci
ativ
eid
enti
tydi
sord
er,d
emen
tia,
illit
erac
y,or
med
ical
inst
abili
ty.
Pai
dfo
rse
ssio
nat
tend
ance
.
458 Journal of Clinical Psychology: In Session, May 2013
Tab
le1
Con
tinu
ed
(b)
Stud
ytr
eatm
ent:
mod
alit
y,do
sage
,tot
alho
urs
(d)
Com
plex
sam
ple
(a)
Mod
el/
Stud
yty
pe/
(and
ince
ntiv
esfo
r(s
ever
e,ch
roni
c,hi
ghly
Stud
yau
thor
atte
ndin
gse
ssio
ns,i
fan
y)(c
)Sa
mpl
eaco
mor
bid,
etc.
)(e
)E
xclu
sion
sfr
omst
udyb
(31)
See
king
Saf
ety
plus
Exp
osur
eT
hera
pyR
evis
edP
rese
nt-
and
past
focu
sed
Pilo
tN
ajav
its
etal
.,20
05
Indi
vidu
al30
sess
ions
×1
hour
=30
hour
sin
5m
onth
s.
5ou
tpat
ient
men
wit
hcu
rren
tP
TSD
and
curr
ent
subs
tanc
ede
pend
ence
(plu
sac
tive
subs
tanc
eus
ein
prio
r60
days
);0%
min
orit
y.
Yes
All
had
child
hood
-bas
edP
TSD
;ave
rage
ofne
ar-d
aily
subs
tanc
eus
e;m
ost
had
acti
vesu
icid
alid
eati
onan
d/or
plan
;al
lhad
subs
tanc
ede
pend
ence
,pr
imar
ilydr
ugra
ther
than
alco
hol;
chro
nic
and
seve
re).
Min
imal
His
tory
ofbi
pola
rI
diso
rder
(man
ia),
psyc
hoti
cdi
sord
er;c
urre
ntly
man
date
dto
trea
tmen
t.
(32)
Sub
stan
ceD
epen
denc
eP
TS
DT
hera
py(S
DP
T)
Pre
sent
-an
dpa
st-f
ocus
edR
CT
Tri
fflem
an,2
000
Indi
vidu
al20
sess
ions
2ti
mes
per
wee
k×
1ho
ur=
40ho
urs.
19m
enan
dw
omen
outp
atie
nts
wit
ha
lifet
ime
diag
nosi
sof
subs
tanc
ede
pend
ence
,at
leas
tcu
rren
tpa
rtia
lPT
SD(2
/3of
sym
ptom
s),a
ndat
tend
edat
leas
ton
ese
ssio
nof
stud
ytr
eatm
ent.
Par
tici
pant
sw
ere
rand
omiz
edto
SDT
P(n
=10
)or
12-S
tep
Fac
ilita
tion
(n=
9);3
7%m
inor
ity.
Yes
Mos
tun
empl
oyed
;SU
Dhi
stor
yw
aspr
imar
ilydr
ugs
rath
erth
anal
coho
l;hi
ghle
vel
ofim
pair
men
ton
num
erou
sba
selin
eva
riab
les.
Mod
erat
eSe
vere
maj
orde
pres
sion
,evi
denc
eof
diss
ocia
tive
iden
tity
diso
rder
,un
trea
ted
man
ia,a
cute
psyc
hosi
s,ac
ute
suic
idal
ity
orho
mic
idal
ity
requ
irin
gco
ntin
uing
invo
lvem
ent
inot
her
ongo
ing
psyc
hoth
erap
yor
hosp
ital
izat
ion.
Review of Treatments 459
Tab
le1
Con
tinu
ed
(b)
Stud
ytr
eatm
ent:
mod
alit
y,do
sage
,tot
alho
urs
(d)
Com
plex
sam
ple
(a)
Mod
el/
Stud
yty
pe/
(and
ince
ntiv
esfo
r(s
ever
e,ch
roni
c,hi
ghly
Stud
yau
thor
atte
ndin
gse
ssio
ns,i
fan
y)(c
)Sa
mpl
eaco
mor
bid,
etc.
)(e
)E
xclu
sion
sfr
omst
udyb
(33)
PT
SD
expo
sure
ther
apy
inco
ntex
tofS
UD
copi
ngsk
ills
trea
tmen
t.P
ast-
focu
sed
inco
ntex
tof
requ
ired
pres
ent-
focu
sed
RC
TC
offe
yet
al.,
2006
Indi
vidu
al1
educ
atio
nals
essi
onan
dth
en6
PT
SDex
posu
rese
ssio
ns×
1ho
ur=
7ho
urs
[pre
cede
dan
dfo
llow
edby
ala
bora
tory
cue
expo
sure
],pr
ovid
edin
cont
ext
ofre
quir
edSU
Dco
ping
skill
str
eatm
ent
(see
deta
ilsin
colu
mn
E).
43m
enan
dw
omen
outp
atie
nts
wit
hcu
rren
tP
TSD
and
curr
ent
alco
hold
epen
denc
e;pl
usal
coho
luse
inpr
ior
60da
ys;
rand
omiz
edto
expo
sure
(n=
X)
vers
usre
laxa
tion
trai
ning
,wit
hbo
thst
udy
cond
itio
nsin
cont
ext
ofre
quir
edpr
esen
t-fo
cuse
dSU
Dco
ping
skill
str
eatm
ent)
;35%
min
orit
y.
Yes
Maj
orit
yw
ith
child
hood
-bas
edP
TSD
,poo
r,dr
ugde
pend
ence
inad
diti
onto
alco
hold
epen
denc
e,m
ulti
ple
prio
rin
pati
ent
trea
tmen
ts.
Maj
orR
equi
red
topa
rtic
ipat
ein
SUD
trea
tmen
t(3
x/w
eek
grou
pco
ping
skill
sth
erap
ypl
us1
indi
vidu
alse
ssio
nev
ery
1–2
wee
ks),
and
drop
ped
from
the
stud
yif
they
ende
dth
eSU
Dtr
eatm
ent;
plus
requ
ired
abst
inen
cefr
omal
lsub
stan
ces
for
4da
yspr
ior
toth
ein
itia
lla
bora
tory
sess
ion,
veri
fied
byur
inal
ysis
;sev
ere
maj
orde
pres
sion
(i.e
.,se
vera
lsy
mpt
oms
inex
cess
ofD
SM
–IV
maj
orde
pres
sion
and
sym
ptom
sm
arke
dly
inte
rfer
ing
wit
hda
ilyliv
ing)
.Als
o,ex
clud
edif
PT
SDdi
agno
sis
was
from
com
bat
orif
they
wer
eno
wor
had
ever
enga
ged
inP
TSD
expo
sure
trea
tmen
t;cu
rren
tps
ycho
tic
diso
rder
;or
man
icep
isod
e.
460 Journal of Clinical Psychology: In Session, May 2013
Tab
le1
Con
tinu
ed
(b)
Stud
ytr
eatm
ent:
mod
alit
y,do
sage
,tot
alho
urs
(d)
Com
plex
sam
ple
(a)
Mod
el/
Stud
yty
pe/
(and
ince
ntiv
esfo
r(s
ever
e,ch
roni
c,hi
ghly
Stud
yau
thor
atte
ndin
gse
ssio
ns,i
fan
y)(c
)Sa
mpl
eaco
mor
bid,
etc.
)(e
)E
xclu
sion
sfr
omst
udyb
(34)
Con
curr
entP
rolo
nged
Exp
osur
eC
OP
EP
rese
ntan
dpa
st-f
ocus
edR
CT
Mill
set
al.,
2012
Indi
vidu
al13
sess
ions
wee
kly
[but
toim
prov
eat
tend
ance
,sch
edul
ing
exte
nded
upto
9m
onth
s]×
1.5
hour
s=
19.5
hour
s.
103
men
and
wom
enou
tpat
ient
sw
ith
curr
ent
PT
SDan
dSU
D(s
ubst
ance
depe
nden
ce);
n=
55in
CO
PE
plus
TA
Uve
rsus
n-48
inT
AU
;min
orit
yun
clea
r(6
%lis
ted
asA
bori
gina
lbut
othe
ret
hnic
itie
sno
tre
port
ed).
Yes
Had
subs
tanc
ede
pend
ence
;m
ost
had
poly
subs
tanc
eus
ean
dhi
stor
yof
inje
ctio
ndr
ugus
e,ha
dex
peri
ence
dse
xual
assa
ult,
had
child
hood
and
repe
ated
trau
ma;
had
atte
mpt
edsu
icid
e(l
ifet
ime)
;an
dw
ere
unem
ploy
ed;c
hron
ican
dse
vere
.
Mod
erat
eSe
lf-h
arm
inpa
st6
mon
ths;
curr
entl
ysu
icid
al(i
deat
ion
plus
plan
and
inte
nt);
curr
ent
psyc
hoti
csy
mpt
oms;
cogn
itiv
eim
pair
men
tth
atm
ight
impe
detr
eatm
ent.
(35)
Cre
atin
gC
hang
eP
ast-
focu
sed
Pilo
tN
ajav
its
&Jo
hnso
n,un
der
revi
ew
Indi
vidu
al17
sess
ions
×1
hour
=17
hour
s ,co
nduc
ted
over
a6
mon
thti
mef
ram
e(t
ypic
ally
wee
kly,
but
allo
win
gfo
rsc
hedu
ling
issu
es).
7m
enan
dw
omen
outp
atie
nts
wit
hcu
rren
tP
TSD
and
curr
ent
SUD
,and
acti
vesu
bsta
nce
use
inpr
ior
30da
ys;7
1%m
inor
ity.
Yes
All
expe
rien
ced
sexu
alab
use;
aver
age
age
offir
sttr
aum
aw
as5;
chro
nic
PT
SDan
dSU
D(e
.g.,
aver
age
ofov
er20
year
sof
mor
eth
anon
esu
bsta
nce
per
day)
.
Min
imal
Cur
rent
bipo
lar
Idi
sord
er(i
.e.,
full
man
ia)
unco
ntro
lled
bym
edic
atio
n;or
curr
ent
psyc
hosi
s.
Not
e.St
udie
sar
elis
ted
inth
efo
llow
ing
orde
r:by
mod
elst
arti
ngw
ith
Seek
ing
Safe
ty,a
sth
atha
sth
em
ajor
ity
ofst
udie
s,an
dal
phab
etic
alby
mod
elaf
ter
that
;all
orga
nize
dfr
ompi
lots
thro
ugh
rand
omiz
edco
ntro
lled
tria
ls,f
ulld
ose
befo
repa
rtia
l-do
se,a
ndby
date
.aA
llre
crui
ted
from
com
mun
ity
unle
ssno
ted
othe
rwis
e;sa
mpl
esi
zeis
atba
selin
e;nu
mbe
rsat
end-
of-t
reat
men
tor
used
for
anal
ysis
may
belo
wer
.bM
inim
alex
clus
ions
defin
edas
:no
excl
usio
ndu
eto
suic
idal
idea
tion
,sel
f-ha
rm,s
ubst
ance
depe
nden
ceno
ran
yot
her
maj
orlim
its.
c WC
DV
S=
Wom
enC
o-O
ccur
ring
Dis
orde
rsan
dV
iole
nce
Stud
y(C
ocoz
zaet
al.,
2005
;Mor
isse
yet
al.,
2006
).
Review of Treatments 461
Tab
le2
Stu
dyR
esul
ts
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(1)
SSpi
lot
Naj
avit
set
al.,
1998
Maj
orit
y(6
3%)o
fth
ose
enro
lled
(of
n=
27re
crui
ted,
the
n=
17w
hoco
mpl
eted
the
min
imum
dose
of>
6se
ssio
ns).
No
•Yes
ondr
ugus
e(A
SIco
mpo
site
),ab
stin
ence
(SU
I,ve
rifie
dby
urin
alys
is)
and
cogn
itio
ns(B
ASU
mea
n).
•Yes
onsu
icid
alth
ough
tsan
dri
sk(S
BQ
item
s),s
ocia
lad
just
men
t(S
AS
tota
lan
dsu
bsca
leex
tend
edfa
mily
role
),co
ping
(CSI
prob
lem
-sol
ving
subs
cale
).
3m
onth
sfr
omen
d-of
-tre
atm
ent;
anal
ysis
from
base
line
(lis
ted
as“3
mon
ths”
)•Y
eson
SU
D:d
rugs
(ASI
com
posi
te),
cogn
itio
ns(B
ASU
mea
n),a
ndal
coho
lfro
men
dof
trea
tmen
tto
follo
w-u
p(A
SIco
mpo
site
).•Y
eson
PT
SD
:(T
SC-4
0to
tala
ndde
pres
sion
subs
cale
).•N
egat
ive
outc
ome:
Incr
ease
inso
mat
izat
ion
(BSI
subs
cale
)at
end
oftr
eatm
ent
and
follo
w-u
p.
•Str
ong
trea
tmen
tsa
tisf
acti
on.
(2)
SSpi
lot
Zlo
tnic
ket
al.,
2003
100%
ofen
rolle
d(f
ull
inte
ntto
trea
t).
•Yes
leve
lof
PT
SDsy
mpt
oms
and
maj
orit
yno
long
erm
etP
TSD
diag
nosi
s(C
AP
S).
Not
asse
ssed
(due
topr
ison
envi
ronm
ent)
.N
otas
sess
ed(n
oot
her
outc
ome
vari
able
s).
•S
tron
gtr
eatm
ent
sati
sfac
tion
.
Bas
elin
eto
6w
eeks
and
3m
onth
s(b
oth
tim
edfr
omre
leas
efr
ompr
ison
);un
clea
rw
hen
rele
ase
was
inre
lati
onto
end
oftr
eatm
ent;
All
anal
yses
base
line
tofo
llow
-ups
;(lis
ted
as“6
wee
ks”
and
“3m
onth
s”)
•Yes
onS
UD
:at
both
6w
eeks
and
3m
onth
s,on
drug
and
alco
hol
seve
rity
,and
also
maj
orit
yno
tus
ing
subs
tanc
es(S
CID
,ver
ified
byur
inal
ysis
).•
Yes
onP
TS
D:a
tbo
th6
wee
ksan
d3
mon
ths,
onle
velo
fsy
mpt
oms
(CA
PS)
.
462 Journal of Clinical Psychology: In Session, May 2013
Tab
le2
Con
tinu
ed
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(3)
SSpi
lot
You
nget
al.,
2003
100%
ofen
rolle
d(f
ull
inte
nt-t
o-tr
eat
anal
ysis
).
•Yes
onsy
mpt
oms
(TSC
-40
tota
lsca
lean
d5
of6
subs
cale
s);
and
rate
ofP
TSD
diag
nosi
sde
crea
sed.
Not
asse
ssed
.•Y
eson
psyc
hopa
thol
ogy
(BSI
tota
land
6of
9su
bsca
les.
)
Not
asse
ssed
.
(4)
SSpi
lot
Maj
orit
y(7
2%)o
fen
rolle
d(o
fth
e25
.•Y
eson
sym
ptom
s(P
CL
).•Y
eson
abst
inen
ce(v
erifi
edby
•Yes
onQ
ualit
yof
Lif
eIn
vent
ory.
Not
asse
ssed
.
Coo
ket
al.,
2006
enro
lled,
n=
18w
hoat
tend
edat
leas
t14
sess
ions
ofSS
and
wer
est
illco
min
gat
the
end
ofth
erap
y).
urin
alys
is).
•Str
ong
trea
tmen
tsa
tisf
acti
on.
(5)
SSpi
lot
Pat
itz
etal
.,un
der
revi
ew
Maj
orit
y(9
6%)o
fsa
mpl
e(n
=23
of24
enro
lled)
.
•Yes
onsy
mpt
oms
(all
10su
bsca
les
ofT
SI).
Not
asse
ssed
.N
otas
sess
ed.
Sati
sfac
tion
not
form
ally
asse
ssed
.
Not
asse
ssed
.
Review of Treatments 463
Tab
le2
Con
tinu
ed
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(6)
SSpi
lot
Dao
ust
etal
.,20
11
100%
ofen
rolle
d(f
ull
inte
nt-t
o-tr
eat
anal
ysis
).
•Yes
onsy
mpt
oms
(PC
Lar
ousa
lsu
bsca
le;T
SC-4
0to
tal
scor
e,an
dsu
bsca
les
diss
ocia
tion
,and
sexu
alab
use
trau
ma
inde
x).
•Yes
onsc
reen
edsy
mpt
oms
(MA
STan
dD
AST
).
•Yes
onfu
ncti
onin
g(B
ASI
S-32
subs
cale
daily
role
).•S
tron
gtr
eatm
ent
sati
sfac
tion
.
Not
asse
ssed
.
(7)
SSpi
lot
Wol
ffet
al.,
2012
Maj
orit
y(6
7%)o
fth
en
=11
1en
rolle
d(n
=74
who
com
plet
edSS
,i.e
.,w
ere
enro
lled
atth
ebe
ginn
ing
and
end
ofSS
,and
nom
ore
than
2un
excu
sed
abse
nces
per
pris
onpo
licy)
.
•Yes
onsy
mpt
oms
(PC
Lfo
rfu
llsa
mpl
ean
dsu
bgro
ups
such
asSM
I,vi
olen
tof
fend
ers,
low
ered
ucat
ion,
etc.
).A
lso
maj
orit
yw
ith
PT
SDat
star
tno
long
erha
dP
TSD
aten
d(P
CL
).
Not
asse
ssed
due
topr
ison
sett
ing.
•Yes
onps
ycho
path
olog
y(B
SIG
loba
lSev
erit
yIn
dex)
.•S
tron
gtr
eatm
ent
sati
sfac
tion
.
Not
asse
ssed
.
464 Journal of Clinical Psychology: In Session, May 2013T
able
2C
onti
nued
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(8)
SSpi
lot
Naj
avit
set
al.,
2013
100%
ofen
rolle
d(f
ull
inte
nt-t
o-tr
eat
anal
ysis
).
•Yes
onsy
mpt
oms
(PC
Lin
trus
ion
subs
cale
;TSI
mea
nan
dsu
bsca
les
anxi
ety,
diss
ocia
tion
,sex
ual
abus
etr
aum
ain
dex,
sex
prob
lem
s)an
dco
gnit
ions
(WA
Sbe
nevo
lenc
esu
bsca
le).
•Yes
onco
gnit
ions
(Gam
bler
sB
elie
fsQ
uest
ionn
aire
mea
nan
dsu
bsca
leill
usio
nof
cont
rol)
.
•Yes
onfu
ncti
onin
g(B
asis
-32
mea
nan
dde
pres
sion
/anx
iety
subs
cale
),ps
ycho
path
olog
y(B
SIm
ean
and
subs
cale
san
xiet
yan
dde
pres
sion
;ASI
psyc
hiat
ric
com
posi
te);
self
-com
pass
ion
(SC
Sm
ean
and
subs
cale
sis
olat
ion,
over
-ide
ntifi
ed,
self
-jud
gmen
t).
Not
asse
ssed
.
•Neg
ativ
eou
tcom
e:em
ploy
men
t(A
SIco
mpo
site
).S
tron
gtr
eatm
ent
sati
sfac
tion
.
(9)
Pee
r-le
dSS
pilo
tN
ajav
its
etal
.und
erre
view
100%
ofen
rolle
d(f
ull
inte
nt-t
o-tr
eat
anal
ysis
).
•Yes
onsy
mpt
oms
(TSC
-40
tota
land
all
6su
bsca
les)
.
Not
asse
ssed
(due
tore
side
ntia
lnat
ure
ofth
epr
ogra
m).
•Yes
onps
ycho
path
olog
y(B
SIto
tala
nd6
of9
subs
cale
s);a
ndSC
S(s
ubsc
ales
self
-jud
gmen
t,is
olat
ion,
and
over
-ide
ntifi
ed).
Not
asse
ssed
.
Str
ong
trea
tmen
tsa
tisf
acti
on.
Review of Treatments 465
Tab
le2
Con
tinu
ed
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(10)
Par
tial
-dos
e(4
0%)
SSpi
lot
Nor
man
etal
.,20
10
Maj
orit
y(6
4%)o
fth
e14
enro
lled
(n=
9w
hoco
mpl
eted
trea
tmen
tand
the
end
oftr
eatm
ent
asse
ssm
ent)
.
•Yes
onsy
mpt
oms
(PC
L).
•Yes
onal
coho
l(n
umbe
rof
drin
king
days
,dri
nks
per
epis
ode)
.
•Yes
onde
pres
sion
(BD
I).S
atis
fact
ion
not
form
ally
asse
ssed
.
3an
d6
mon
ths
(app
ears
tobe
tim
edfr
omen
dof
trea
tmen
t).
•Yes
onP
TS
D:(
PC
L).
Unc
lear
onSU
D(l
owas
sess
men
tco
mpl
etio
n).
(11)
Par
tial
-dos
e(3
2%)
SSpi
lot
Sear
cy&
Lip
ps,
2012
100%
ofen
rolle
d(f
ull
inte
nt-t
o-tr
eat
anal
ysis
).
•Yes
onsy
mpt
oms
(TSC
-40
tota
land
all
6su
bsca
les)
.
Not
asse
ssed
(due
tore
side
ntia
lnat
ure
ofth
epr
ogra
m).
Not
asse
ssed
Tre
atm
ent
sati
sfac
tion
was
not
form
ally
asse
ssed
.
Not
asse
ssed
.
(12)
Unc
lear
dose
SSpi
lot
Ben
ton
etal
.,20
11,2
012
♦U
ncle
arR
esul
tsre
port
edon
lyfo
rth
ose
who
com
plet
edat
leas
ton
ese
ssio
n.N
oda
taon
how
man
ydi
dno
tat
tend
atle
ast
one
sess
ion.
♦N
oon
PT
SD(M
PSS
R;T
SC-4
0).
♦N
oon
SUD
(AD
OM
,i.e
.,nu
mbe
rof
days
usin
gsu
bsta
nces
inpa
stm
onth
,but
mos
tw
ere
abst
inen
tat
base
line,
per
clin
icpo
licy
and
com
plet
ion
ofSU
DIO
Ppr
ior
toSS
).
♦N
oon
othe
rva
riab
les:
func
tion
ing
(BA
SIS-
32to
tal,
subs
cale
s).
Str
ong
trea
tmen
tsa
tisf
acti
on.
6-m
onth
follo
w-u
pfr
omen
dof
trea
tmen
t;an
alys
isfr
omba
selin
efo
ral
lva
riab
les,
plus
end
oftr
eatm
entt
ofo
llow
-up
for
AD
OM
and
BA
SIS
-32
slee
psu
bsca
leon
ly;(
liste
das
“6m
onth
s”)
•Yes
onP
TS
Dsy
mpt
oms
and
diag
nosi
s(M
PSS
Rdi
agno
stic
cuto
ff,
tota
l,an
dsu
bsca
les
re-e
xper
ienc
ing
and
arou
sal;
TSC
-40
depr
essi
onan
dsl
eep
subs
cale
s,w
ith
the
latt
eral
sosi
gnifi
cant
from
end
oftr
eatm
ent
tofo
llow
-up)
.•N
oon
SU
D.
•Yes
onot
her
vari
able
s:fu
ncti
onin
g(B
ASI
S-32
subs
cale
sre
lati
onto
self
and
othe
rs,a
ndps
ycho
sis)
.•N
egat
ive
outc
ome:
end
oftr
eatm
ent
tofo
llow
-up
ther
ew
asan
incr
ease
inal
coho
luse
.
466 Journal of Clinical Psychology: In Session, May 2013
Tab
le2
Con
tinu
ed
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(13)
SS cont
rolle
dtr
ial
Gat
zet
al.,
2007
100%
ofen
rolle
d(f
ull
inte
nt-t
o-tr
eat
anal
ysis
).
Not
rate
d(n
oen
d-of
-tre
atm
ent
asse
ssm
ent)
.
Not
rate
d(n
oen
d-of
-tre
atm
ent
asse
ssm
ent)
.
Not
rate
d(n
oen
d-of
-tre
atm
ent
asse
ssm
ent)
.S
tron
gtr
eatm
ent
sati
sfac
tion
(per
Bro
wn
etal
.,20
07).
8m
onth
sfr
omen
dof
trea
tmen
t;an
alys
isfr
omba
selin
e(l
iste
das
“12
mon
ths”
)Y
eson
PT
SD
:•S
Sou
tper
form
edth
eco
ntro
lon
sym
ptom
s(P
SS).
Yes
onS
UD
:•B
oth
cond
itio
nsim
prov
edon
drug
and
alco
hol(
ASI
com
posi
tes)
.Y
eson
othe
rva
riab
les:
•SS
outp
erfo
rmed
the
cont
rolo
ntr
eatm
ent
atte
ndan
ce.
•Bot
hco
ndit
ions
impr
oved
onps
ycho
path
olog
y(B
SIG
loba
lSe
veri
tyIn
dex)
.
(14)
(del
iver
edby
case
man
ager
s)SS co
ntro
lled
tria
lD
esai
etal
.,20
08,2
009
100%
ofen
rolle
d(f
ull
inte
nt-t
o-tr
eat
anal
ysis
).
Yes •S
Sou
tper
form
edth
eco
ntro
lon
sym
ptom
s(P
CL
tota
l,an
dav
oida
nce
subs
cale
).•B
oth
SSan
dth
eco
ntro
lim
prov
edon
PC
Lsu
bsca
lehy
perv
igila
nce.
Yes • B
oth
SSan
dth
eco
ntro
lim
prov
edon
drug
and
alco
hol(
ASI
com
posi
tes)
.
Yes •S
Sou
tper
form
edth
eco
ntro
lon
soci
alsu
ppor
t.•B
oth
SSan
dth
eco
ntro
lim
prov
edon
psyc
hopa
thol
ogy
(SC
L,A
SIps
ychi
atri
cco
mpo
site
),da
ysho
mel
ess,
self
-est
eem
,an
dhe
alth
(SF
-12
med
ical
scor
e).
Tre
atm
ent
sati
sfac
tion
was
not
form
ally
asse
ssed
.
6m
onth
follo
w-u
pfr
omen
dof
trea
tmen
t;an
alys
esar
eba
selin
eth
roug
hfo
llow
-up
(lis
ted
as“1
2m
onth
s”).
Yes
onP
TS
D:
•SS
outp
erfo
rmed
the
cont
rolo
nsy
mpt
oms
(PC
Lto
tala
ndsu
bsca
les
avoi
danc
ean
dar
ousa
l).
•Bot
hco
ndit
ions
impr
oved
onP
CL
intr
usio
n.Y
eson
SU
D:
•Bot
hSS
and
the
cont
rolo
nal
coho
land
drug
s(A
SIco
mpo
site
s).
Yes
onot
her
vari
able
s:•S
Sou
tper
form
edth
eco
ntro
lon
soci
alsu
ppor
t,da
ysw
orke
d,an
dps
ycho
path
olog
y(S
CL
-30)
.•B
oth
cond
itio
nsim
prov
edon
heal
th(S
F-1
2m
edic
alsc
ore)
,ps
ycho
path
olog
y(A
SIps
ychi
atri
cco
mpo
site
and
SF12
men
tals
core
),da
ysho
mel
ess
and
self
-est
eem
.
Review of Treatments 467
Tab
le2
Con
tinu
ed
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(15)
SS cont
rolle
dtr
ial
Lyn
chet
al.,
2012
100%
ofen
rolle
d(f
ull
inte
nt-t
o-tr
eat
anal
ysis
).
Yes •S
Sou
tper
form
edco
ntro
lon
sym
ptom
s(P
CL
).
Not
asse
ssed
due
topr
ison
sett
ing.
Yes • S
Sou
tper
form
edco
ntro
lon
allo
ther
vari
able
sas
sess
ed:
depr
essi
on(C
ES-
D);
rela
tion
ship
func
tion
ing
(IIP
);ad
apti
veco
ping
,and
mal
adap
tive
copi
ng(s
core
son
Bri
efC
OP
E);
and
onam
ount
ofre
liabl
ech
ange
.
Not
asse
ssed
.
Tre
atm
ent
sati
sfac
tion
was
not
form
ally
asse
ssed
.
(16)
SSR
CT
hybr
idH
ien,
Coh
enet
al.,
2004
Yes •S
Sou
tper
form
edT
AU
onfr
eque
ncy
and
seve
rity
ofsy
mpt
oms
(PSS
-SR
and
CA
PS)
.•B
oth
SSan
dR
Pim
prov
edon
the
abov
eva
riab
les.
Yes • S
Sou
tper
form
edT
AU
onse
veri
ty(S
UI
tota
l)ve
rifie
dby
urin
alys
is).
•Bot
hSS
and
RP
impr
oved
onth
eab
ove
vari
able
s.
Yes • S
Sou
tper
form
edT
AU
onps
ycho
path
olog
y(B
SIto
tal,
HD
RS
tota
ls).
•Bot
hSS
and
RP
impr
oved
onth
eab
ove
vari
able
s.
Yes
onP
TS
D:
• SS
outp
erfo
rmed
TA
Uw
ith
sust
aine
dim
prov
emen
tson
freq
uenc
yan
dse
veri
tyof
sym
ptom
s(P
SS-S
Ran
dC
AP
S)at
6-an
d9-
mon
thfo
llow
-ups
.•B
oth
SSan
dR
Pim
prov
edon
the
abov
eva
riab
les.
Yes
onS
UD
:•S
San
dR
Pou
tper
form
edT
AU
wit
hsu
stai
ned
impr
ovem
ents
ondr
ugus
ese
veri
ty(S
UI)
at6-
and
9-m
onth
follo
w-u
ps.
•Bot
hSS
and
RP
impr
oved
onth
eab
ove
vari
able
s.
468 Journal of Clinical Psychology: In Session, May 2013
Tab
le2
Con
tinu
ed
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(17)
SSR
CT
Naj
avit
set
al.,
2006
100%
ofen
rolle
d(f
ull
inte
nt-t
o-tr
eat
anal
ysis
).
Yes •S
Sou
tper
form
edth
eco
ntro
lon
cogn
itio
ns(W
AS
bene
vole
nce
subs
cale
).
Yes •S
Sou
tper
form
edth
eco
ntro
lon
subs
tanc
eus
epr
oble
ms
(7su
bsca
les
ofth
eP
EI
incl
udin
gpo
lydr
ugus
e,pr
eocc
upat
ion
wit
hdr
ugs,
loss
ofco
ntro
l,et
c.);
asw
ell
asA
xis
ISU
Dsy
mpt
oms
(AP
S));
and
cogn
itio
ns(R
FU
).
Yes •S
Sou
tper
form
edth
eco
ntro
lon
Axi
sI
anor
exia
,so
mat
izat
ion,
and
Axi
sII
pers
onal
ity
diso
rder
fact
oran
dob
sess
ive-
com
puls
ive
(AP
Ssc
ore/
subs
cale
).M
oder
ate
trea
tmen
tsa
tisf
acti
on.
3m
onth
sfr
omen
dof
trea
tmen
t;an
alys
isfr
omba
selin
e(l
iste
das
“3m
onth
s”)
Yes
onS
UD
:•S
Sou
tper
form
edth
eco
ntro
lsub
stan
ceus
epr
oble
ms
(7su
bsca
les
ofP
EI
incl
udin
gpo
lydr
ugus
e,pr
eocc
upat
ion
wit
hdr
ugs,
loss
ofco
ntro
l,et
c.);
asw
ella
sA
xis
ISU
Dsy
mpt
oms
(AP
S);a
ndco
gnit
ions
(RF
U).
Yes
ontr
aum
a/P
TS
D:
•SS
outp
erfo
rmed
the
cont
rolo
nsy
mpt
oms
(TSC
Csu
bsca
les
sexu
alco
ncer
nsan
dse
xual
dist
ress
)an
dco
gnit
ions
(WA
Ssu
bsca
lebe
nevo
lenc
e).
Yes
onot
her
vari
able
s:•S
Sou
tper
form
edth
eco
ntro
lon
psyc
hopa
thol
ogy
(AP
Ssu
bsca
les
Axi
sI
anor
exia
,som
atiz
atio
n,m
ajor
depr
essi
on).
(18)
SSR
CT
Bod
enet
al.,
2012
100%
ofel
igib
lera
ndom
ized
sam
ple
(ful
lint
ent-
to-t
reat
anal
ysis
).
No
Nei
ther
SSno
rco
ntro
lim
prov
edon
sym
ptom
s(I
ES-
R).
Yes •S
Sou
tper
form
edth
eco
ntro
lon
drug
use
(ASI
com
posi
te).
•Bot
hSS
and
cont
rol
impr
oved
onal
coho
l(A
SIco
mpo
site
).
Yes •S
Sou
tper
form
edth
eco
ntro
lon
allo
ther
vari
able
s:at
tend
ance
,co
ping
(CR
I),a
ndcl
ient
sati
sfac
tion
(CSQ
).S
tron
gtr
eatm
ent
sati
sfac
tion
.
3m
onth
follo
w-u
pfr
omen
d-of
-tre
atm
ent;
anal
ysis
from
base
line.
(“6
mon
thfo
llow
-up”
)Y
eson
PT
SD
:•B
oth
SSan
dco
ntro
lim
prov
edon
sym
ptom
s(I
ES-
R).
Yes
onS
UD
:•S
Sou
tper
form
edth
eco
ntro
lon
drug
s(A
SIco
mpo
site
;31%
grea
ter
redu
ctio
n).
•Bot
hSS
and
cont
roli
mpr
oved
onal
coho
l(A
SIco
mpo
site
).N
oot
her
vari
able
sw
ere
asse
ssed
atth
isti
mep
oint
.
Review of Treatments 469
Tab
le2
Con
tinu
ed
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(19)
Par
tial
-do
se(%
vari
ed)
SSR
CT
Zlo
tnic
ket
al.,
2009
100%
ofth
ose
rand
omiz
ed(f
ull
inte
nt-t
o-tr
eat
anal
ysis
).
Not
asse
ssed
(no
outc
ome
asse
ssm
ent
cond
ucte
dat
end
ofac
tive
phas
eof
trea
tmen
t).
Not
asse
ssed
(no
outc
ome
asse
ssm
ent
cond
ucte
dat
end
ofac
tive
phas
eof
trea
tmen
t).
Not
asse
ssed
(no
outc
ome
asse
ssm
ent
cond
ucte
dat
end
ofac
tive
phas
eof
trea
tmen
t).
Tre
atm
ents
atis
fact
ion
was
stro
ng(a
ndw
asth
eon
lyva
riab
lera
ted
atth
een
dof
the
acti
veph
ase
oftr
eatm
ent)
.
3fo
llow
-ups
:(A
)1–
1.5
mon
ths
from
end
ofac
tive
phas
e(g
roup
trea
tmen
tin
pris
on,
liste
das
“12
wee
ksaf
ter
inta
ke”)
;(B
)4.
25-4
.75
mon
ths
from
end
ofac
tive
phas
e(l
iste
das
“3m
onth
spo
st-r
elea
sefr
ompr
ison
”).
(C)
7.25
-7.7
5m
onth
sfr
omen
dof
activ
eph
ase
(lis
ted
as“6
mon
ths
post
-rel
ease
from
pris
on”)
.A
llan
alys
esar
efr
omba
selin
eun
less
othe
rwis
ein
dica
ted.
Yes
onP
TS
D:
•Bot
hco
ndit
ions
impr
oved
onP
TSD
(CA
PS
tota
lsco
re)
atA
,B,a
ndC
tim
epoi
nts.
•SS
outp
erfo
rmed
cont
rolo
nco
mpl
extr
aum
asy
mpt
oms
(TSC
-40)
inth
atSS
had
impr
ovem
ent
atea
chti
mep
oint
A,B
,and
C,w
here
asco
ntro
lhad
iton
lyat
A.
Yes
onS
UD
:•B
oth
cond
itio
nsim
prov
edon
drug
use
(ASI
com
posi
te)
atth
etw
oav
aila
ble
tim
epoi
nts
(Ban
dC
).Y
eson
othe
rva
riab
les:
•Bot
hco
ndit
ions
impr
oved
onps
ycho
path
olog
y(B
SIto
tal)
atti
mep
oint
sA
,B,a
ndC
.•S
Sou
tper
form
edco
ntro
lon
psyc
hopa
thol
ogy
(BSI
tota
l),i
mpr
ovin
gfr
omA
toB
,and
Ato
C,w
here
asco
ntro
ldid
not.
•Bot
hco
ndit
ions
impr
oved
onle
galp
robl
ems
(ASI
com
posi
te)
atti
mep
oint
sB
and
C.
•Neg
ativ
eou
tcom
e:C
ontr
olou
tper
form
edSS
onal
coho
l(A
SIco
mpo
site
)at
one
tim
epoi
nt(B
).
470 Journal of Clinical Psychology: In Session, May 2013
Tab
le2
Con
tinu
ed
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(20)
Par
tial
-do
se(2
4%)
SSR
CT
Ghe
eet
al.,
2009
Maj
orit
y(7
1%)o
fth
ose
enro
lled
(of
51w
omen
,the
n=
36w
hoat
tend
edat
leas
t5
ofth
e6
Seek
ing
Safe
tyse
ssio
ns).
Yes •S
Sou
tper
form
edth
eco
ntro
lon
sym
ptom
s(M
PSS
;and
TSC
-40
sexu
alab
use
trau
ma
inde
x(t
hela
tter
was
the
only
subs
cale
anal
yzed
).
Unc
lear
No
pre-
to-p
ost
SUD
outc
ome;
and
the
maj
orit
yin
both
cond
itio
nsdi
dno
tpr
ovid
ean
endp
oint
urin
esa
mpl
e.N
odi
ffer
ence
inpe
rcen
tne
gati
veur
inal
yses
betw
een
the
two
cond
itio
ns(u
sing
the
stan
dard
assu
mpt
ion
that
am
issi
ngur
ine
isco
ded
posi
tive
).
Not
asse
ssed
.N
otas
sess
ed.
Review of Treatments 471
Tab
le2
Con
tinu
ed
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(21)
Par
tial
-do
se(4
8%)
SS
RC
TH
ien
etal
.,20
09
100%
ofen
rolle
d(f
ull
inte
nt-t
o-tr
eat
anal
ysis
).
Yes •B
oth
SSan
dW
HE
impr
oved
onP
TSD
freq
uenc
yan
dse
veri
tyto
tals
core
s(P
SS-S
Ran
dC
AP
S).
No
for
over
alls
ampl
e•N
eith
erSS
nor
Con
trol
(WH
E)
impr
oved
ondr
ugus
e(S
UI
veri
fied
byur
inal
ysis
and
saliv
ate
stin
g)or
alco
holo
rdr
ug(A
SIco
mpo
site
s).
Yes
onse
cond
ary
anal
yses
(see
next
row
).
Yes
onot
her
vari
able
s•S
Sou
tper
form
edW
HE
onH
IVse
xual
risk
(RB
Sto
talH
IVR
isk)
,eat
ing
diso
rder
s(E
DE
Qto
tal)
,and
ther
apeu
tic
allia
nce
(HA
Q-I
Ito
tal)
.•B
oth
SSan
dco
ntro
l(W
HE
)re
duce
dbi
nge
eati
ng(E
DE
Qsu
bsca
le).
Yes
onP
TS
D:
•Bot
hSS
and
WH
Esu
stai
ned
impr
ovem
ents
onP
TSD
(PSS
-SR
,C
AP
S).
No
onS
UD
:•
Nei
ther
SSno
rC
ontr
ol(W
HE
)im
prov
edon
drug
use
(SU
Ive
rifie
dby
urin
alys
isan
dsa
liva
test
ing)
oral
coho
lor
drug
(ASI
com
posi
tes)
.
“”
End
oftr
eatm
ents
econ
dary
anal
yses
†(e
ach
belo
wa
sepa
rate
pape
r).
Yes
onP
TS
D:
•SS
outp
erfo
rmed
WH
Eon
redu
cing
PT
SDse
veri
tyan
dfr
eque
ncy
and
subs
cale
arou
sal(
PSS
-SR
)am
ong
alco
holm
isus
ers
(n=
111)
.Y
eson
SU
D:
•SS
outp
erfo
rmed
WH
Eon
alco
hola
ndco
cain
ese
veri
ty(A
SIco
mpo
site
)am
ong
heav
ysu
bsta
nce
use
grou
pw
ith
PT
SDim
prov
emen
ts(n
=17
4).
•SS
outp
erfo
rmed
WH
Eon
alco
hola
ndco
cain
ese
veri
ty(A
SIco
mpo
site
)am
ong
trea
tmen
tti
trat
ors
(n=
86).
•SS
outp
erfo
rmed
WH
Eon
alco
hol(
ASI
com
posi
te)
amon
g12
-Ste
pat
tend
ees
who
atte
nded
12-s
tep
regu
larl
yaf
ter
trea
tmen
t.B
utW
HE
outp
erfo
rmed
SS
onal
coho
l(A
SIco
mpo
site
)am
ong
thos
ew
hodi
dno
tat
tend
12-s
tep
regu
larl
yaf
ter
trea
tmen
t.•S
Sou
tper
form
edW
HE
onst
imul
ant
use
outc
omes
(ASI
);am
ong
heav
yst
imul
ant
user
s;no
diff
eren
ces
for
nons
tim
ulan
tan
dlig
htst
imul
ant
user
s.•S
Sou
tper
form
edW
HE
inm
edia
tion
effe
cts:
i.e.,
SSou
tper
form
edW
HE
inre
duci
ngP
TSD
whi
chin
turn
was
asso
ciat
edw
ith
low
eral
coho
land
coca
ine
use;
the
effe
cts
wer
egr
eate
stam
ong
thos
ew
hore
ceiv
edth
em
ost
sess
ions
.Y
eson
othe
rva
riab
les:
•SS
outp
erfo
rmed
WH
Eon
redu
cing
unsa
fese
xual
occa
sion
s(R
BS)
amon
gth
ose
wit
hhi
ghri
skse
xual
beha
vior
atba
selin
e.•S
Sou
tper
form
edW
HE
onal
lianc
e(H
AQ
-II)
,as
note
din
colu
mn
Eab
ove,
and
high
eral
lianc
ew
asre
late
dto
decr
ease
dP
TSD
and
high
ertr
eatm
ent
atte
ndan
ce.
† Sec
onda
ryan
alys
esar
ere
port
edon
this
stud
ybe
caus
eit
isth
eon
lyst
udy
wit
hsu
ffici
ent
sam
ple
size
topr
ovid
eri
goro
usse
cond
ary
anal
yses
inre
lati
onto
asp
ecifi
ctr
eatm
ent
mod
el.
472 Journal of Clinical Psychology: In Session, May 2013
Tab
le2
Con
tinu
ed
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(22)
WIT
pilo
tC
ovin
gton
etal
.,20
08
♦A
min
orit
y(2
1.8%
;n
=44
ofth
en
=20
2el
igib
lesa
mpl
e)O
fn=
202
elig
ible
,onl
yth
ose
who
com
plet
edth
ere
side
ntia
lSU
Dpr
ogra
m(n
=15
7of
the
202)
plus
com
plet
edth
ere
side
ntia
lpro
gram
“suc
cess
fully
”(d
efine
das
havi
ng“c
ompl
eted
thei
rtr
eatm
ent
plan
sor
goal
s”be
fore
exis
ting
the
resi
dent
ialS
UD
prog
ram
;n=
86of
the
157)
,plu
sco
mpl
eted
both
part
sof
WIT
(HW
Ran
dB
T)
and
all
asse
ssm
ents
(n=
44).
♦Y
eson
sym
ptom
s(T
SC-4
0su
bsca
les
anxi
ety,
diss
ocia
tion
,de
pres
sion
,sle
ep;f
orth
ose
who
com
plet
edbo
thH
WR
and
BT,
i.e.,
the
WIT
mod
el,
plus
succ
essf
ully
com
plet
edth
eS
UD
resi
dent
ialp
rogr
am,
plus
did
alla
sses
smen
tpo
ints
;see
atle
ft).
♦N
oda
tare
port
ed.
♦Y
eson
depr
essi
on(B
DI;
for
thos
ew
hoco
mpl
eted
both
HW
Ran
dB
T(i
.e.,
the
WIT
mod
el)
plus
succ
essf
ully
com
plet
edth
eS
UD
resi
dent
ial
prog
ram
plus
did
all
asse
ssm
entp
oint
s;se
eat
left
).♦
Neg
ativ
eou
tcom
e:un
clea
r;no
nere
port
edfo
rth
esa
mpl
ead
dres
sed,
but
nore
port
onth
ose
who
drop
ped
out
ofW
IT.
Not
asse
ssed
.
Review of Treatments 473
Tab
le2
Con
tinu
ed
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(23)
GR
TR
CT
Mes
sina
etal
.,20
10
100%
ofra
ndom
ized
(ful
lint
ent
totr
eat)
.N
otas
sess
ed.
Not
asse
ssed
.N
otas
sess
ed.
Tre
atm
ent
sati
sfac
tion
not
asse
ssed
.
Follo
w-u
psw
ere
aver
age
of9
mon
ths
and
14m
onth
sfr
ompa
role
,i.e
.re
leas
efr
ompr
ison
(whi
chw
asno
tnec
essa
rily
end
oftr
eatm
ent)
;an
alys
isis
base
line
thro
ugh
12m
onth
s(f
ollo
w-u
pslis
ted
as“6
and
12m
onth
s”af
ter
pris
onre
leas
e).
PT
SDno
tas
sess
ed.
Yes
onS
UD
:B
oth
GR
Tan
dT
AU
impr
oved
onal
coho
land
drug
(ASI
com
posi
tes)
.Y
eson
othe
rva
riab
les:
•Bot
hG
RT
and
TA
Uim
prov
edon
psyc
hopa
thol
ogy
(ASI
psyc
hiat
ric
com
posi
te).
•GR
Tim
prov
edon
fam
ily(A
SIco
mpo
site
)bu
tT
AU
did
not
(but
onw
ithi
n-gr
oup,
not
betw
een-
grou
pan
alys
is).
•Neg
ativ
eou
tcom
e:T
AU
impr
oved
onSe
lf-E
ffica
cybu
tG
RT
did
not
(but
onw
ithi
n-gr
oup,
not
betw
een-
grou
pan
alys
is).
(24)
ICB
Tpi
lot
McG
over
net
al.,
2009
♦A
min
orit
y(4
7.8%
)of
the
elig
ible
sam
ple
(of
n=
23el
igib
le,
n=
11w
hoco
mpl
eted
atle
ast
two
sess
ions
ofIG
BT
and
had
atle
ast
one
follo
w-u
pas
sess
men
t).
♦Y
eson
sym
ptom
s(C
AP
Sto
tala
ndsu
bsca
les
reex
peri
enci
ng,
avoi
danc
e,ar
ousa
l).
♦Y
eson
alco
hola
nddr
ugs
(ASI
com
posi
tes)
.
Not
asse
ssed
.T
reat
men
tsa
tisf
acti
onno
tas
sess
ed.
♦3
mon
ths
from
end
oftr
eatm
ent;
prim
ary
anal
ysis
isen
dof
trea
tmen
tto
follo
w-u
p.•Y
eson
PT
SD
:sym
ptom
s(C
AP
Sto
tala
ndsu
bsca
lear
ousa
l).
No
onSU
Don
alco
holo
rdr
ugs
(ASI
com
posi
tes)
.N
oot
her
vari
able
sas
sess
ed.
474 Journal of Clinical Psychology: In Session, May 2013
Tab
le2
Con
tinu
ed
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(25)
ICB
TR
CT
McG
over
net
al.,
2011
♦D
esig
nst
ates
inte
ntto
trea
t.H
owev
er,
52%
mor
epa
rtic
ipan
tsw
ere
rand
omiz
edto
ICB
Tth
anto
IDC
(wit
hno
rati
onal
eno
rde
scri
ptio
nof
the
rand
omiz
atio
npr
oced
ure)
,res
ulti
ngin
very
uneq
ual
sam
ple
size
sat
base
line.
Not
repo
rted
.N
otre
port
ed.
Not
repo
rted
.T
reat
men
tsa
tisf
acti
onno
tas
sess
ed.
♦A
llbe
low
are
appr
oxim
atel
y3
mon
ths
from
end
oftr
eatm
ent;
anal
ysis
from
base
line
(lis
ted
as“6
mon
ths”
).♦
Sam
ple
size
sar
eno
tre
port
edfo
ran
you
tcom
ean
alys
es,o
ther
than
noti
ngth
at53
%of
the
sam
ple
was
avai
labl
eat
follo
w-u
p.Y
eson
PT
SD
:•I
CB
Tou
tper
form
edID
Con
diag
nosi
san
dre
-exp
erie
ncin
gsu
bsca
le(C
AP
S).
•Bot
hIC
BT
and
IDC
impr
oved
onsy
mpt
oms
(CA
PS
tota
land
subs
cale
sav
oida
nce
and
arou
sal)
.Y
eson
SU
D:
•Bot
hIC
BT
and
IDC
impr
oved
(day
sof
drug
use.
Yes
onot
her
vari
able
s:•B
oth
ICB
Tan
dID
Cim
prov
edon
psyc
hopa
thol
ogy
(ASI
com
posi
te)
and
depr
essi
on(B
DI)
.
(26)
TA
RG
ET
RC
TF
rism
anet
al.,
2008
♦D
esig
nst
ates
inte
ntto
trea
t.H
owev
er,
98%
mor
epa
rtic
ipan
tsw
ere
rand
omiz
edto
TA
RG
ET
than
toT
AU
,res
ulti
ngin
very
uneq
uals
ampl
esi
zes
atba
selin
e.(R
easo
nst
ated
was
toim
prov
eat
tend
ance
atT
AR
GE
T).
Not
rate
d(n
oen
d-of
-tre
atm
ent
asse
ssm
ent)
.
Not
rate
d(n
oen
d-of
-tre
atm
ent
asse
ssm
ent)
.
Not
rate
d(n
oen
d-of
-tre
atm
ent
asse
ssm
ent)
.
♦Fo
llow
-up
appr
oxim
atel
y4
and
10m
onth
sfr
omen
dof
trea
tmen
t;an
alys
isfr
omba
selin
e(l
iste
das
“6m
onth
s”an
d“1
2m
onth
s”fr
omba
selin
e).
Unc
lear
onSU
D:
•Bot
hco
ndit
ions
appe
arto
impr
ove
(GA
INsu
bsca
lesu
bsta
nce
freq
uenc
yin
dex;
and
perc
enta
ges
on3
item
s:dr
ink
toin
toxi
cati
on,
use
any
drug
s,an
dsu
bsta
nce
abus
e).
Unc
lear
onP
TSD
.U
ncle
aron
othe
rva
riab
les.
•Bot
hco
ndit
ions
appe
arto
impr
ove
onan
xiet
yan
dde
pres
sion
(GA
INsu
bsca
les)
.
Review of Treatments 475
Tab
le2
Con
tinu
ed
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(27)
TR
EM
cont
rolle
dtr
ial
Tous
sain
tet
al.,
2007
100%
ofen
rolle
din
clud
edin
outc
ome
anal
ysis
(ful
lin
tent
-to-
trea
tan
alys
is).
Not
repo
rted
(no
end-
of-t
reat
men
tas
sess
men
t).
Not
rate
d(n
oen
d-of
-tre
atm
ent
asse
ssm
ent)
.
Not
rate
d(n
oen
d-of
-tre
atm
ent
asse
ssm
ent)
.
Follo
w-u
pap
prox
imat
ely
2an
d8
mon
ths
from
end
oftr
eatm
ent;
anal
ysis
from
base
line
(lis
ted
as“6
mon
ths”
and
“12
mon
ths”
from
base
line)
.U
ncle
aron
PT
SD:
No
diff
eren
cebe
twee
nco
ndit
ions
atei
ther
follo
w-u
ppo
int,
and
noac
ross
-tim
est
atis
tica
ltes
ting
repo
rted
(PSS
).U
ncle
aron
SUD
:N
odi
ffer
ence
betw
een
cond
itio
nsat
eith
erfo
llow
-up
poin
t,an
dno
acro
ss-t
ime
stat
isti
calt
esti
ngre
port
ed(A
SIdr
ug,a
lcoh
olco
mpo
site
s).
Yes
onan
othe
rva
riab
le:
TR
EM
outp
erfo
rmed
cont
rolo
nps
ycho
path
olog
y(B
SIsu
bsca
leG
SI)
at8
mon
ths
afte
rtr
eatm
ent.
(28)
BC
M/
TR
EM
cont
rolle
dtr
ial
Am
aro
etal
.,20
07a,
2007
b
100%
ofen
rolle
d(f
ull
inte
nt-t
o-tr
eat
anal
ysis
).
Not
rate
d(n
oen
d-of
-tre
atm
ent
asse
ssm
ent)
.
Not
rate
d(n
oen
d-of
-tre
atm
ent
asse
ssm
ent)
.
Not
rate
d(n
oen
d-of
-tre
atm
ent
asse
ssm
ent)
.T
heau
thor
sre
port
stro
ngsa
tisf
acti
onw
ith
BC
M(2
007a
);ho
wev
er,t
wo
ofth
ree
sati
sfac
tion
rati
ngs
wer
eno
tsi
gnifi
cant
lydi
ffer
ent
betw
een
the
two
cond
itio
ns.
Follo
w-u
ps6
and
12m
onth
sfr
omba
selin
e;un
clea
rho
wth
ese
tim
epoi
nts
rela
teti
me-
wis
eto
end
ofB
CM
orT
RE
Man
alys
isfr
omba
selin
e.Y
es/U
ncle
aron
PT
SD
:B
CM
outp
erfo
rmed
the
cont
roli
nth
eac
ross
-tim
ean
alys
isfr
omba
selin
eth
roug
h12
mon
ths
onsy
mpt
oms
(PSS
);un
clea
rat
6m
onth
s.Y
eson
SU
D:
Bot
hco
ndit
ions
impr
oved
onal
coho
land
drug
s(A
SIco
mpo
site
s)fr
omba
selin
eth
roug
h12
mon
ths.
Yes
/Unc
lear
onan
othe
rva
riab
le:
BC
Mou
tper
form
edth
eco
ntro
lin
the
acro
ss-t
ime
anal
ysis
from
base
line
thro
ugh
12m
onth
son
psyc
hopa
thol
ogy
(BSI
GSI
);un
clea
rat
6m
onth
s.
476 Journal of Clinical Psychology: In Session, May 2013
Tab
le2
Con
tinu
ed
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(29)
TR
EM
cont
rolle
dtr
ial
Fal
lot
etal
.,20
11
100%
ofen
rolle
d(f
ull
inte
ntto
trea
t).
Not
rate
d(n
oen
d-of
-tre
atm
ent
asse
ssm
ent)
.
Not
rate
d(n
oen
d-of
-tre
atm
ent
asse
ssm
ent)
.
Not
rate
d(n
oen
d-of
-tre
atm
ent
asse
ssm
ent)
.
2m
onth
sbe
fore
end
oftr
eatm
ent(
liste
das
6m
onth
s)an
d4
mon
ths
afte
rtr
eatm
ente
nded
(lis
ted
as12
mon
ths)
;ana
lysi
sfr
omba
selin
eth
roug
h4
mon
ths.
Yes
onS
UD
:(bu
trep
orte
don
lyon
thos
epo
siti
vefo
rS
UD
atba
selin
e;le
ssth
anha
lfth
efu
llsa
mpl
e).
•TR
EM
plus
inte
grat
edtr
aum
ase
rvic
es+
TA
Uou
tper
form
edT
AU
onal
coho
land
drug
use
(ASI
com
posi
tes)
for
the
subs
ampl
ew
how
ere
usin
gat
base
line.
Yes
onP
TS
D:
Bot
hco
ndit
ions
impr
oved
onP
TSD
(PSS
).Y
eson
othe
rva
riab
les:
•psy
chop
atho
logy
(BSI
scor
es:G
SI,s
ubsc
ale
depr
essi
on,h
osti
lity)
.N
egat
ive
outc
ome:
•U
ncle
ar.M
eans
for
TR
EM
onal
coho
land
drug
sar
ein
dire
ctio
nof
wor
seni
ngfr
om6
mon
ths
to12
mon
ths
(in
cont
rast
toth
eco
ntro
l),
but
noan
alys
esad
dres
s6
vers
us12
mon
ths
for
any
vari
able
s.
(30)
CT
PC
Dpi
lot
Bra
dyet
al.,
2001
♦A
min
orit
y(3
8.5%
)of
the
orig
inal
sam
ple
(fro
mth
eor
igin
aln
=39
,the
yre
port
onth
en
=15
who
com
plet
ed10
orm
ore
sess
ions
,i.e
.,62
.5%
,of
the
trea
tmen
t).
♦Y
esfo
rtr
eatm
ent
com
plet
ers
onsy
mpt
oms
(CA
PS
tota
land
thre
esu
bsca
les;
IES
intr
usio
nsu
bsca
le;
and
Mis
siss
ippi
Scal
e).
♦Y
esfo
rtr
eatm
ent
com
plet
ers
onal
coho
lan
ddr
ugs
(ASI
com
posi
tes)
.
♦Y
esfo
rtr
eatm
ent
com
plet
ers
onps
ycho
path
olog
y(A
SIps
ychi
atri
cco
mpo
site
and
BD
I).
Follo
w-u
p6
mon
ths
from
end
oftr
eatm
ent;
anal
ysis
from
base
line
(lis
ted
as“6
mon
ths”
).♦
Yes
for
trea
tmen
tcom
plet
ers;
atfo
llow
-up
this
is13
%of
the
orig
inal
sam
ple
(n=
7).
•PT
SD
sym
ptom
s:(C
AP
Ssu
bsca
lehy
pera
rous
alan
dM
issi
ssip
piSc
ale)
.•S
UD
alco
hola
nddr
ug(A
SIco
mpo
site
s).
•Oth
erva
riab
les:
psyc
hopa
thol
ogy
(BD
I);a
ndem
ploy
men
t(A
SIco
mpo
site
).
Review of Treatments 477
Tab
le2
Con
tinu
ed
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(31)
SSpi
lot
Naj
avit
set
al.,
2005
100%
ofen
rolle
d(f
ull
inte
nt-t
o-tr
eat
anal
ysis
).
•Yes
onsy
mpt
oms
(TSC
-40
tota
l;su
bsca
les
anxi
ety,
diss
ocia
tion
,and
sexu
altr
aum
ain
dex)
and
cogn
itio
ns(W
AS
subs
cale
mea
ning
fuln
ess)
.
•Yes
ondr
ugs
(ASI
com
posi
te,v
erifi
edby
urin
alys
is).
•Yes
fam
ily/s
ocia
lpr
oble
ms
(ASI
com
posi
te),
func
tion
ing
(GA
F),
psyc
hopa
thol
ogy
(BSI
host
ility
subs
cale
),an
dov
eral
lcha
nge
(CG
IS).
Not
asse
ssed
.
Str
ong
trea
tmen
tsa
tisf
acti
on.
(32)
SDP
Tpi
lot
Tri
fflem
an,
2000
♦U
ncle
arR
esul
tsre
port
edon
lyfo
rth
ose
who
com
plet
edat
leas
ton
ese
ssio
n.N
oda
taon
how
man
ydi
dno
tat
tend
atle
ast
one
sess
ion.
♦Y
esB
oth
SDP
and
12SF
impr
oved
onsy
mpt
oms
and
diag
nosi
s(C
AP
Sto
tal,
num
ber
ofsy
mpt
oms,
and
perc
ent
posi
tive
for
PT
SD).
♦Y
esB
oth
SDP
and
12SF
impr
oved
onon
eit
em(A
SInu
mbe
rof
days
ofsu
bsta
nce
use)
.
♦Y
esB
oth
SDP
and
12SF
impr
oved
onps
ycho
path
olog
y(A
SIps
ychi
atri
cco
mpo
site
).
1m
onth
from
end
oftr
eatm
ent;
anal
ysis
isba
selin
eto
follo
w-u
p.•Y
eson
SU
D:
Bot
hSD
Pan
d12
SFim
prov
edon
drug
(ASI
com
posi
te),
num
ber
ofda
ysus
ing
asu
bsta
nce.
•Yes
onP
TS
D:
Bot
hSD
Pan
d12
SFim
prov
edon
sym
ptom
san
ddi
agno
sis
(CA
PS
tota
l,nu
mbe
rof
sym
ptom
s,an
dpe
rcen
tpo
siti
vefo
rP
TSD
).•Y
eson
anot
her
vari
able
:B
oth
SDP
and
12SF
impr
oved
onps
ycho
path
olog
y(A
SIps
ychi
atri
cco
mpo
site
).
478 Journal of Clinical Psychology: In Session, May 2013
Tab
le2
Con
tinu
ed
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(33)
Exp
osur
epl
usSU
Dtr
eatm
ent
RC
TC
offe
yet
al.,
2006
♦A
min
orit
y(3
9.5%
)of
the
orig
inal
sam
ple.
(Of
n=
43en
rolle
d,th
en
=17
who
atte
nded
the
init
ial
lab
sess
ion
plus
all6
clin
ical
sess
ions
,i.e
.,50
%of
thos
eas
sign
edto
expo
sure
,63%
tore
laxa
tion
).
♦Y
esE
xpos
ure
plus
SU
Dtr
eatm
ent
outp
erfo
rmed
SU
Dal
one
for
trea
tmen
tco
mpl
eter
s(I
ES-
R).
♦N
egat
ive
outc
ome:
Non
elis
ted,
but
uncl
ear
due
tore
port
ing
ofre
sult
son
lyfo
rtr
eatm
ent
com
plet
ers.
Not
asse
ssed
(no
end
oftr
eatm
ent
SUD
asse
ssm
ent)
.
Not
asse
ssed
.N
otas
sess
ed(n
ofo
llow
-up)
.
(34)
CO
PE
RC
TM
ills
etal
.,20
12
100%
ofra
ndom
ized
(ful
lint
ent-
to-t
reat
anal
ysis
).
No
diff
eren
cebe
twee
nC
OP
Ean
dT
AU
onsy
mpt
oms
ordi
agno
sis
(CA
PS)
atth
eti
mep
oint
clos
est
toen
dof
trea
tmen
t(3
mon
ths)
.
No
diff
eren
cebe
twee
nC
OP
Ean
dT
AU
onsy
mpt
oms
ordi
agno
sis
(CID
I),n
ornu
mbe
rof
drug
clas
ses
used
(OT
I)at
the
tim
ecl
oses
tto
end
oftr
eatm
ent
(3m
onth
s).
No
diff
eren
cebe
twee
nC
OP
Ean
dT
AU
onsy
mpt
oms
orde
pres
sion
(BD
I-II
),no
ran
xiet
y(S
TA
I)at
the
tim
epoi
ntcl
oses
tto
end
oftr
eatm
ent
(3m
onth
s).N
ow
ithi
n-gr
oup
anal
ysis
prov
ided
from
base
line
toth
isti
mep
oint
.
6m
onth
sfr
omen
dof
trea
tmen
t,an
alys
isfr
omba
selin
e(l
iste
das
“9m
onth
s”).
Yes
onP
TS
D:
•CO
PE
outp
erfo
rmed
TA
Uon
sym
ptom
s(C
AP
S).
•Bot
hC
OP
Ean
dth
eco
ntro
lim
prov
edon
diag
nosi
s(C
AP
S).
Yes
onS
UD
:•B
oth
cond
itio
nsim
prov
edon
seve
rity
and
diag
nosi
s(o
nC
IDI)
,and
num
ber
ofdr
ugcl
asse
sus
ed(O
TI)
.Y
eson
othe
rva
riab
les:
•Bot
hco
ndit
ions
impr
oved
onde
pres
sion
(BD
I-II
)an
dan
xiet
y(S
TA
I).
Review of Treatments 479
Tab
le2
Con
tinu
ed
(A)
Stud
ynu
mbe
r(s
eeT
able
1)
(B)
Out
com
ere
sult
sar
ere
port
edon
wha
tpe
rce
ntof
the
orig
inal
sam
ple
recr
uite
d?
(C)
Posi
tive
outc
omes
for
PT
SD
/tra
uma
(pre
-to
end-
of-
trea
tmen
t)?
(D)
Posi
tive
outc
omes
for
subs
tanc
eus
e/ad
dict
ion
(pre
-to
end-
of-t
reat
men
t)?
(E)
Posi
tive
othe
rou
tcom
es(p
re-
toen
d-of
-tre
atm
ent)
?A
lso
trea
tmen
tsa
tisf
acti
on?
(F)
Posi
tive
outc
omes
atfo
llow
-up2
for
PT
SD/t
raum
a,SU
D,a
ndot
her
vari
able
s(a
ndan
you
tcom
esin
dica
ting
ane
gati
veou
tcom
e(w
orse
ning
over
tim
e,or
the
cont
rolo
utpe
rfor
min
gth
eex
peri
men
tal
trea
tmen
t)
(35)
CC
pilo
tN
ajav
its
&Jo
hnso
n,un
der
revi
ew
100%
ofen
rolle
din
clud
edin
outc
ome
anal
ysis
(ful
lin
tent
-to-
trea
tan
alys
is).
•Yes
onsy
mpt
oms
(PC
Lto
tala
ndav
oida
nce
subs
cale
;T
SC-4
0to
tala
nd5
subs
cale
s);a
ndco
gnit
ions
(WA
Sto
tal)
.
•Yes
onco
gnit
ions
(BA
SUto
tal)
.•Y
eson
func
tion
ing
(BA
SIS-
32to
tal,
and
subs
cale
sde
pres
sion
/anx
iety
and
daily
livin
g),
psyc
hopa
thol
ogy
(BSI
tota
land
6su
bsca
les)
,co
ping
(CSI
soci
alsu
ppor
tsu
bsca
le),
self
-har
mco
gnit
ions
(SB
Q).
Not
asse
ssed
.
Str
ong
trea
tmen
tsa
tisf
acti
on.
Not
e.1.
We
are
only
repo
rtin
gsi
gnifi
cant
diff
eren
ces.
Any
null
findi
ngs
(“no
diff
eren
ce”)
are
not
repo
rted
,as
thes
eof
ten
refle
ctlim
ited
pow
er/s
ampl
esi
ze.A
lso,
notr
ends
are
repo
rted
(onl
yre
sult
sof
p<
.05)
and
only
resu
lts
onps
ycho
met
rica
llyva
lidin
stru
men
ts.
2.U
nles
sot
herw
ise
indi
cate
d,al
lfol
low
-ups
liste
din
follo
w-u
pco
lum
nar
eti
med
from
end
oftr
eatm
ent
tobe
com
para
ble
acro
ssst
udie
s.3.
♦Thi
ssy
mbo
lind
icat
esab
senc
eof
asu
ffici
ent
sam
ple
(les
sth
anha
lfof
thos
een
rolle
d)an
dth
usca
utio
nne
eded
inin
terp
reti
ngth
est
udy
resu
lts.
4.Sc
ale
abbr
evia
tion
s:A
PS
Ado
lesc
ent
Psy
chop
atho
logy
Scal
e;A
SI
Add
icti
onSe
veri
tyIn
dex;
BA
SIS
-32
Beh
avio
ran
dSy
mpt
omId
enti
ficat
ion
Scal
e(3
2it
emve
rsio
n);
BA
SU
Bel
iefs
Abo
utSu
bsta
nce
Use
;BD
I-II
Bec
kD
epre
ssio
nIn
vent
ory,
2nd
edit
ion;
BS
IB
rief
Sym
ptom
Inve
ntor
y;B
SI
GS
IB
rief
Sym
ptom
Inve
ntor
yG
loba
lSev
erit
yIn
dex;
CA
PS
Clin
icia
nA
dmin
iste
red
PT
SDSc
ale;
CID
IC
ompo
site
Inte
rnat
iona
lDia
gnos
tic
Inte
rvie
w;C
GIS
Clin
ical
Glo
balI
mpr
essi
ons
Scal
e;C
RI
Cop
ing
Res
pons
esIn
vent
ory;
CS
IC
opin
gSt
rate
gies
Inve
ntor
y;C
SQ
Clie
ntSa
tisf
acti
onQ
uest
ionn
aire
;DA
TS
Dru
gA
buse
Scre
enin
gT
est;
ED
EQ
Eat
ing
Dis
orde
rsE
xam
inat
ion
Que
stio
nnai
re;H
AQ
IIH
elpi
ngA
llian
ceQ
uest
ionn
aire
vers
ion
2;H
DR
SH
amilt
onR
atin
gSc
ale
for
Dep
ress
ion;
IES
-RIm
pact
ofE
vent
sSc
ale-
Rev
ised
;IIP
Inve
ntor
yof
Inte
rper
sona
lPro
blem
s;G
AF
Glo
balA
sses
smen
tof
Fun
ctio
ning
;G
AIN
Glo
bal
App
rais
alof
Indi
vidu
alN
eeds
;M
AS
TM
ichi
gan
Alc
ohol
Scre
enin
gT
est;
MP
SS
Mod
ified
PT
SDSy
mpt
omSc
ale;
OT
IO
piat
eT
reat
men
tIn
dex;
PC
LP
TSD
Che
cklis
t;P
EI
Per
sona
lE
xper
ienc
esIn
vent
ory;
PS
DS
Post
trau
mat
icSt
ress
Dia
gnos
tic
Scal
e;P
SS
PT
SDSy
mpt
omSc
ale
and
PS
S-R
revi
sed
vers
ion;
PT
CI
Post
-T
raum
atic
Cog
niti
ons
Inve
ntor
y;R
FU
Rea
sons
for
Usi
ng;S
AS
Soci
alA
djus
tmen
tSc
ale;
SB
QSu
icid
alB
ehav
iors
Que
stio
nnai
re;S
CID
Stru
ctur
edC
linic
alIn
terv
iew
for
DSM
IV;
SC
SSe
lf-C
ompa
ssio
nSc
ale;
ST
AI
Stai
t-T
rait
Anx
iety
Inve
ntor
y;S
UI
Subs
tanc
eU
seIn
vent
ory;
TS
C-4
0T
raum
aSy
mpt
omC
heck
list
40;T
SC
CT
raum
aSy
mpt
omC
heck
list
for
Chi
ldre
n;T
SI
Tra
uma
Sym
ptom
Inve
ntor
y;W
AS
Wor
ldA
ssum
ptio
nsSc
ale.