It wasn't so bad because I wasn't physically injured I should have said ‘no’ more

1. Post Traumatic Stress DisorderWe can offer better help … if we know howReg NixonAssociate Professor, School of PsychologyFlinders University18 February 2014

2. ‘My heart’s desire had been that I alone should perish…here at Troy; that you should sail…[home].’ – Achilles, standing above Patroklos’s corpse (The Illiad, Homer; translation cited in Shay, 1991).

3. It wasn't so bad because I wasn't physically injured • I should have said ‘no’ more • People are dangerous • People can't be trusted • Something terrible will happen again • I can't protect myself • I am damaged Sexual assault victim, 2013

4. Trauma exposure 75% (Australia) • PTSD prevalence 6.4% (12-month, Australia) • 79-85% have a comorbid disorder • PTSD individuals have 1.5-2 times the health costs of those without PTSD • At best, only 50% have received treatment, could be as low as 8% • Relative to other anxiety disorders, sufferers: • Have higher health costs • Lower quality of life • Are 2nd only to Agoraphobia in work loss days • Have more suicidal ideation and attempts, even after prior mood disorder is controlled

5. Released August 2013 • TF-CBT ✔ • EMDR ✔ • Cochrane Review / Bisson (2005, 2013) • ISTSS / Foa et al., (2009) • ACPMH Guidelines (2007) • NICE (2005)

6. Effective Treatments Are Not Always Used for PTSD Becker, Zayfert, & Anderson, 2004

7. Rosen et al., 2004; Russell & Silver, 2007.

8. Always Not at all van Minnen et al., 2010

9. Some critical factors for successful dissemination, implementation and sustained practice change

10. Practitioner • Pre-existing skills • Beliefs, esp. re: evidence-based practice, and beliefs specific to trauma-focussed therapy Cook et al. 2004; Couineau & Forbes, 2011; Ruzek & Rosen, 2009.

11. Training • Accessibility, cost • Stand alone versus ongoing consult/support, format of training • Availability of supervisors etc. Cook et al. 2004; Couineau & Forbes, 2011; Ruzek & Rosen, 2009.

12. System • Trauma-informed (including screening and assessment) • Group cohesiveness • Leadership • Practical – staffing levels, resources, waiting lists Cook et al. 2004; Couineau & Forbes, 2011; Ruzek & Rosen, 2009.

13. Recent Initiatives in Australia Step 2 – If so, how to make it routine practice (sustainability) • VVCS – dissemination project • Australian Defence Force – dissemination project Step 1 – Does TF-CBT actually work in routine clinical settings? • Yarrow Place – effectiveness trial • Veterans and Veterans Families Counselling Service (VVCS) – effectiveness trial

14. Yarrow Place - Recent Sexual Assault Survivors • Cognitive Processing Therapy (CPT) compared to Treatment as Usual (TAU) • CPT clinicians – 3 day workshop, then weekly consultation • CPT = 6 x 90min sessions • TAU = TAU • N.B. No significant differences between groups in terms of therapeutic alliance.

15. PTSD Checklist (PCL) 8-11 TAU continue to have further sessions versus 1 CPT between post-3mths d = -0.10 d = 0.30 d = 0.16 d = 0.13 d = 0.32 Cut-off Intent-to-treat sample

16. Results – % achieving good end-state functioning1 1Good end-state functioning defined as < 20 on the Clinician-Administered PTSD Scale

17. VVCS Effectiveness Trial Forbes, Lloyd, Nixon et al., 2012, J Anxiety Disorders. • Cognitive Processing Therapy (CPT) compared to Treatment as Usual (TAU) • CPT clinicians – workshop, then weekly consultation • CPT = 12 sessions • TAU = TAU • N.B. No significant differences between groups in therapeutic working alliance

19. Treatment Outcomes - PTSD(3 months follow-up) CPT: 67% had clinically significant improvements 38% no longer met DSM criterion for PTSD 27% achieved good end-state functioning (remission) TAU: 35% had clinically significant improvements 13% no longer met DSM criterion for PTSD 3% achieved good end-state functioning

20. VVCS Dissemination • A focus on sustainability • Organizational readiness to implement the intervention • e.g., reducing case loads to allow CPT preparation time: short-term service pain for long-term client and service gain • Monitoring • e.g., embedding PCL into electronic clinical records • Supervisors and deputy directors took part in workshop and consultation • [Less consult than RCT– fortnightly for 6-month period] • Two booster workshops following consultation process

21. d = 1.02 Preliminary findings: • Large effect of treatment • Clinician adherence to CPT protocol good (~80%) • CPT Competence – 88% of sessions rated satisfactory or better (i.e., good/very good/excellent) • 47% of clients fell below cut-off in an average of 8 sessions.

22. Australian Defence Force Ongoing Dissemination Project: • Clients are active duty personnel • Mixture of military and non-military trauma presentations • Training - workshop, 3-months weekly consultation, 3-months fortnightly consultation

23. Preliminary findings

24. Where to from here?

25. Where to from here? • Research, training and treatment • Optimal but most cost-efficient training methods • How to overcome barriers to dissemination (individual, organisational etc.) • TF-CBT supervisors – how to retain the knowledge • Long-term assessment of implementation required (skills and quality of treatment maintained?) • Policy • Emphasis on cost-benefit analysis of improved treatment methods

26. And if we get research, training, and policy right Ok, maybe we can’t help Achilles…

27. And if we get research, training, and policy right After therapy: • I did nothing to deserve this • I did not bring about this event - he did it • I did everything I could do • This was a significant event but I can cope with it • I am a good person and a good mother • I am brave and strong • Most people are good • [PCL = 17] Before therapy: • I should have fought back more • People are dangerous • People will hurt you if you let your guard down • People can't be trusted • Something terrible will happen again • I can't protect myself • I am damaged • [PCL = 64] Therapist: Samantha Angelakis

28. Acknowledgments Collaborators David Forbes, Delyth Lloyd, Dzenana Kartal, Anne-Laure Couineau, Meaghan O’Donnell, Richard Bryant Funding agencies Australian Rotary Health Research Foundation, Department of Veterans’ Affairs, Flinders University Clients and staff: • Yarrow Place • VVCS • ADF • Victim Support Service Flinders staff and students • Talitha Best, Lisa Beatty, Sarah Wilksch, Samantha Angelakis, Nathan Weber

29. Questions?