adding exposure treatment to SSRI treatment con- ferred additional benefits in patients who did not respond to previous pharmacotherapy (Otto et al.,
2003; Rothbaum et al.,2006). Evidence from one of our treatment studies (Başoğlu et al., 2003b) shows that antidepressants do not contribute to improve- ment in PTSD when used together with CFBT (see
Figure 6.2).
It is worth noting that antidepressants are also not very effective in alleviating depressive symptoms. A meta-analysis (Kirsch et al.,2008) of all clinical trials submitted to the US Food and Drug Administration for the licensing of antidepressants found that, compared with placebo, the new-generation SSRIs did not pro- duce clinically significant improvements in patients who initially had moderate or even severe depression, but showed significant effects only in the most severely depressed patients. Thefindings also showed that the effect for these patients seems to be due to decreased responsiveness to placebo, rather than increased responsiveness to medication. Thesefindings were sup- ported by another review (Anderson et al.,2008) con- ducted for the purposes of revising the British Association for Psychopharmacology guidelines for treating depressive disorders with antidepressants. This review found only 20% of difference in drug versus placebo response rates with 55–65% of patients having significant residual symptoms after antidepressant treatment. Response to antidepressants increased in most severely depressed patients, which was related to decreased responsiveness to placebo. These two studies concluded that there is little reason to prescribe new- generation antidepressant medications to any but the most severely depressed patients unless alternative treatments have been ineffective.
An additional problem concerning drug trials in PTSD is that thefindings have limited generalizability
because most studies involved middle-aged females sexually abused as children or Vietnam Veterans (Friedman and Davidson, 2007). There is also less evidence on the efficacy of medications in different age groups, because concerns about increased suicides among children and adolescents treated with SSRIs for depression and concerns about safety, age-related pharmacokinetic capacity, drug-drug interactions, and comorbid medical conditions in elderly people pose obstacles to pharmacotherapy research in these populations (Friedman and Davidson,2007). Finally, when used in combination with exposure-based treat- ments, drugs may undermine the efficacy of the latter by facilitating attributions of improvement to the tab- lets rather than to personal efforts (Başoğlu et al.,
1994a). In view of these findings, it is only fair to conclude that the use of antidepressants as afirst-line intervention in treatment of trauma survivors can hardly be justified.
Implications for cognitive-behavioral
treatment
The effects of exposure treatment on sense of control are well known to cognitive-behavioral therapists (e.g. Barlow, 2002; Marks and Dar, 2000). It is likely that some therapists observe such effects in their patients and perhaps even utilize strategies to boost their sense of control. Indeed, certain procedures used in behavior therapy (e.g. removal of safety signals during exposure) serve to increase sense of control in patients. Nevertheless, an intervention that does not have a sharp focus on the critical therapeutic processes is likely to have weaknesses. For example, the control-enhancing effects of exposure treatment are more likely to be coincidental or erratic (i.e. benefiting some but not others), and thus at times weak when the treatment focus is on fear reduction and when the attributional processes that lead to increased sense of control are not intentionally and specifically targeted and facilitated in every way possible. This might perhaps explain in part thefindings from a meta-analysis of treatment studies of PTSD (Bradley et al.,2005) showing that 47% of the cases treated with exposure, 53% of cases treated with CBT, and 44% of cases treated with exposure and cog- nitive restructuring did not improve at the end of treat- ment. A sharper focus on avoidance and sense of control might enhance the efficacy of treatment, elim- inate its redundant components, reduce therapist involvement (thereby enhancing self-reliance and
sense of control), and thus facilitate its dissemination on a largely self-help basis.
A shift in treatment aims from anxiety reduction to enhancement of sense of control might not only enhance motivation for and compliance with treatment but also achieve greater and faster reduction in help- lessness and associated stress responses. Presenting treatment merely as a means of reducing anxiety might have a limited effect on motivation. After all, as far as the patient is concerned, there are much easier ways of reducing fear than exposure treatment, such as avoiding fear-evoking situations, reliance on safety sig- nals (e.g. carrying tablets), or taking anxiolytics. Moreover, setting anxiety reduction as the main goal in therapy against which progress is assessed and rewarded might further undermine sense of control in some patients whose anxiety fluctuates in response to various situational variables in an exposure session. This is generally true for most anxiety disorders. People with panic disorder and agoraphobia, for exam- ple, might show reduced fear in a supermarket but attribute this to the fact that the supermarket was not very crowded or that they woke up feeling generally better that day. Such characteristic ‘yes but’ responses (yes, I didn’t panic but this was because . . . ) reflect insufficient sense of control, arising from the fact that anxiety cues in the same feared situation show signifi- cant variability from one occasion to another. A feared situation is never the same on two occasions in terms of its threat value. Such ever-changing nature of the fear stimuli might require repeated exposures to the same situation to ensure an adequate increase in sense of control when the patient perceives the treatment goal as reduction in fear. A control-focused approach might circumvent this problem by making treatment success contingent on lasting reversal of avoidance behavior, regardless of fear. In any event, such behavioral change and associated sense of control often lead to substantial reduction in fear. Those cases that show only partial or no reduction in fear during exposure, often regarded as treatment failures (Marks and Dar, 2000), are more likely to benefit from this approach, provided that a lasting reduction in avoidance can be achieved.
The effectiveness of a treatment involving only live exposure also raises questions about the need for cer- tain commonly used interventions in CBT programs, such as imaginal exposure (e.g. Foa et al., 1999; Foa et al.,2005; Marks et al.,1998), cognitive restructuring (e.g. Blanchard et al.,2003; Bryant et al.,2003; Ehlers et al.,2003; Tarrier et al.,1999), and various anxiety
management techniques including relaxation training, coping skills training, breathing training, thought stopping, and guided self-dialogue (e.g. Cloitre et al.,
2002; Foa et al.,1999; Glynn et al., 1999; Lee et al.,
2002). Ourfindings are consistent with available evi- dence suggesting that cognitive interventions (Foa et al., 2005; Marks et al., 1998; Paunovic and Öst,
2001) or anxiety management techniques (Foa et al.,
1999; Foa et al.,1991) do not confer additional benefits
when used in combination with exposure.
Imaginal exposure might not be as potent as live exposure, as also noted by Devilly and Foa (2001) in their comment on the possible reasons for a relatively small effect size reported for imaginal exposure in a treatment study (Tarrier et al., 1999). Indeed, in a meta-analysis (Bradley et al.,2005) of treatment stud- ies of PTSD, the mean effect size for interventions involving imaginal exposure combined with live expo- sure was twice as large as that for imaginal exposure alone (1.78 vs. 0.91; means recalculated by the present authorsŞalcıoğlu et al.,2007a). The superiority of live over imaginal exposure might be explained by the fact that the former involves exposure to both past trauma memories and cues that signal future threat. For exam- ple, we have observed in our last study (Başoğlu et al.,
2007) that exposure to simulated tremors in an earth- quake simulator evokes not only fear of future earth- quakes but also distress associated with past trauma memories, thus providing opportunities for gaining control over both types of stressors. We also noted that live exposure triggers much more vivid and wider range of trauma-related memories and imagery than would be possible in imaginal exposure. Furthermore, although imaginal exposure reduces the distress asso- ciated with trauma memories, such improvement might not generalize when it is not accompanied by increased sense of control associated with reduction in behavioral avoidance. Unfortunately, most studies have not reported treatment effects specifically on behavioral avoidance so we do not know if imaginal exposure reduces avoidance (or increases sense of con- trol) before any actual live exposure takes place. In one of the few studies that examined this issue (Keane et al., 1989) imaginal exposure was not effective in reducing avoidance, a finding which might explain why improvement did not generalize to other symp- toms, such as emotional numbing and guilt. In con- clusion, our results suggest that better results could be obtained, while also saving considerable therapist time and effort, by giving priority to live exposure in
therapy and using the other techniques only when the patient is having difficulty in conducting exposure. Therapist involvement in exposure could also be limited to such cases.
Finally, our findings imply that certain compo- nents of traditional behavior therapy, such as exposure homework tasks, weekly monitoring of progress, ver- bal reinforcement, and diary keeping are not always required for treatment success. Such time consuming practices might perhaps be reserved for more severely ill cases or those that pose problems of compliance. In setting treatment targets priority needs to be given to anxiety- or distress-evoking situations that contribute most to feelings of helplessness. Such situations are not necessarily the ones that are associated with highest levels of anxiety. Conversely, exposure does not always need to involve the most distressing cues to have sig- nificant impact on sense of control; low intensity stressors might achieve the same effect. Furthermore, repeated and lengthy exposure sessions until fear sub- sides might not be necessary. Exposure could be ter- minated when the person feels in control.
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