The use of empirically supported treatment components for trauma exposure: The role of therapist training and characteristics
Traumatic events, or exposure to actual or threatened death, serious injury, or sexual violence, are unfortunately part of many people’s lives. Exposure to traumatic events can lead to life-disrupting consequences for children and adults including mental health disorders such as depression, anxiety, and posttraumatic stress disorder (PTSD). PTSD is one of the most common negative consequences of trauma exposure (Bradley, Greene, Russ, Dutra, & Westen, 2005; Cohen, Mannarino, & Deblinger, 2006). Fortunately, treatments for PTSD are effective, and a few have been identified as “probably efficacious” (Chambless & Hollon, 1998). Eye Movement Desensitization and Reprocessing (EMDR) and Cognitive Behavior Therapy (CBT) were among the treatments identified as probably efficacious for the treatment of PTSD in adults and children and are considered empirically-supported treatments (ESTs). However, there is a disconnect between how we study treatments such as CBT and EMDR in controlled research environments and how the treatments are actually used in community practitioners’ offices. The efficacy of ESTs when used in parts and pieces is unknown. Some researchers have begun to identify the most successful and commonly used components of treatments. However, there is a need for theory and data to understand the components of empirically supported treatments that are in fact frequently used by community therapists and the therapist characteristics such as training, background, and personality factors, that may predict their use.
The current study therefore focused on components of the ESTs CBT and EMDR, as I investigated what individual parts and pieces of the treatments are being used in community settings and to attempt to understand why certain techniques are employed to a greater or lesser extent in practice. To accomplish this, I surveyed 346 community therapists who were primarily female (84.07%) and white (86.98%), with a mean age of 44.59 years. Therapists in the study were trained in the ESTs CBT and EMDR, with 272 participants (78.61%) trained in CBT and 135 participants (39.02%) trained in EMDR.
The Therapists’ Experiences with Empirically Supported Treatment Components Questionnaire (EST-Q) was created for this study. Specifically, the EST-Q asks therapists to rate how often they use the 32 different EST components. This questionnaire allowed me to examine the frequency of the use of these components. I hypothesized that 1) items on the EST-Q would load onto at least two factors: one with mainly CBT techniques and one with EMDR techniques (there may also be a factor with items crossing the two techniques). In fact, four subscales named CBT, EMDR, Both (a factor containing items that are representative of both CBT and EMDR modalities), and Exposure (a factor for items relating to exposure sessions that should be used in TF-CBT) emerged.
Next, 2) I hypothesized that EMDR therapists would use EMDR techniques at a higher frequency than CBT therapists. There was a significant main effect of the EST-Q subscales, such that if we ignore the type of therapist the rating came from, the ratings of the four EST-Q subscales significantly differed. There was also a significant between-subjects effect of therapist type, such that if we ignore the EST-Q subscale rating, different types of therapists (CBT, EMDR, both, and neither) gave different ratings. There was also a significant interaction between the type of therapist and EST-Q subscale, suggesting that the profile of ratings across different types of therapists was different for different EST-Q subscales. EMDR therapists did in fact have higher mean scores on their EMDR subscale than CBT therapists had on their CBT subscale [t(194) = 3.937, p < .001]. Additionally, therapists who reported being trained in “Both” CBT and EMDR, had significantly higher mean scores on the EMDR subscale than the CBT subscale [t(208) = 6.583, p < .001], indicating that therapists trained in both CBT and EMDR were more likely to endorse using more EMDR treatment elements more often than CBT treatment elements.
In addition to the above hypotheses, this dissertation research also aimed to add descriptive information about the use of various EST techniques and about therapists’ use of the components of CBT and EMDR. For example, psychoeducation about trauma, or providing “the client information about traumatic experiences, trauma reactions, symptoms, and trauma reminders,” was the most commonly endorsed empirically supported treatment element.
Finally, in order to delve deeper into these quantitative findings, qualitative interviews were conducted with a small sample (n = 10) of practicing community therapists. Interview questions were framed around the research question, “What are the experiences of therapists who use components of the empirically-supported treatments Eye Movement Desensitization and Reprocessing (EMDR) and Cognitive Behavioral Therapy (CBT)?” Qualitative data was analyzed using an inductive coding approach, guided by grounded theory. The data gathered in qualitative interviews found 14 a priori themes based on the questions asked to the participants, as well as 14 different emergent themes coded in the data. I briefly discuss themes that help illuminate the quantitative data. A priori themes discussed in this document include: 1) What kind of treatment modalities do you utilize? 2) How do you choose the right treatment modality for each client? and 3) Do you use exposure sessions when treating clients with trauma exposure/PTSD? Emergent themes discussed in this document include: 1) Single incident vs. complex trauma [and/or Big T (Trauma) vs. Little t (trauma)], 2) EMDR vs. exposure sessions/therapy, and very brief discussions of 3) EMDR vs. CBT, 4) Money commitment in EMDR, and 5) Thought EMDR sounded “crazy.”
Implications, limitations, and future directions of this research are also discussed.