Pragmatic Case Studies in Psychotherapy

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July 19, 2017 -- From the Editor 


Written Exposure Therapy as Step One in Reducing the Burden of PTSD: The Composite Cases of "Alex," "Bruno," and "Charles"    

*** David Austern, The Steven A. Cohen Military Family Clinic at NYU Langone Medical Center, NY, NY 


***  Jeffrey Cigrang, Wright State University, and Alan Peterson, University of Texas Health Science Center & South Texas Veterans Health Care System, San Antonio, TX  

*** Denise Sloan and Brian Marx, National Center for PTSD, VA Boston Healthcare System, & Boston School of Medicine   

Response to Commentaries 

*** David Austern, The Steven A. Cohen Military Family Clinic at NYU Langone Medical Center, NY, NY   

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          In recent years, the gold standard for the evidence-based treatment of military veterans and others with Post-Traumatic Stress Disorder (PTSD) has been sustained exposure in clinical context with extensive and in-depth contact with a psychotherapist, as exemplified in Edna Foa and colleagues' Prolonged Exposure Therapy (PE) and Patricia Resick and colleagues' Cognitive Processing therapy (CPT). While both of these latter therapies are relatively short (generally 12 sessions and 8-15 sessions, respectively) by psychotherapy standards, by some PTSD client standards they can be too long and/or too emotionally painful for an exposure-based therapy. Moreover, they require intense emotional investment by the therapist, leading at times to burnout.

        Enter Denise Sloan and Brian Marx and colleagues 13 years ago with 5-session Written Expressive Therapy (WET), an approach that builds on the exposure-based principles of PE and CPT, but involves less than half the number of sessions and considerably less than half the therapist time, which is spent in much less emotionally demanding tasks. Basically, the therapist provides some psycho-education, asks the client to write about the trauma, and monitors that the writing instructions were followed, without processing the content of the writing. Sloan, Marx, et al.'s research so far provides preliminary, quantitative-group evidence of WET's effectiveness with adults with PTSD, and they are now conducting a non-inferiority, randomized clinical trial to compare WET with a version of CPT with this population.

        Now enter David Austern. Inspired by the preliminary clinical findings with WET, Austern created three composite, systematic case studies of clients provided WET treatment, based on his clinical experience working in a PTSD clinic, to illustrate different scenarios of how WET could function in a stepped-care model. One of the clients ("Alex") was clinically successful with WET only; a second client ("Bruno") required more treatment after WET and was clinically successful in completing a full course of prolonged exposure; and a third client ("Charles") required Prolonged Exposure after WET, but dropped out after only two sessions, with little clinical success.

        Jeffrey Cigrang and Alan Peterson, two well-known PTSD researchers, comment specifically on stepped-care models for PTSD and reflect on the value of incorporating Motivational Interviewing principles as well as particular homework tasks into these efforts. They underscore the issue of burnout prevention.

        The second commentary by Sloan and Marx, developers of WET, provide fascinating and crucial details about WET's background and ongoing development as these themes relate to Austern's case studies.

        Austern responds to a variety of the issues the commentators raise, with a particular focus on the potential of stepped-care service delivery models to make PTSD care more efficient.     

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** Manuscripts. Two types of manuscripts are desired: those consisting of one or more case studies, and those consisting of case method articles.

** Suggested Author Guidelines. These can be found by clicking on the link Instructions for Authors, as described above. Note that we suggest 11 common headings for case study manuscripts:
1. Case Context and Method
2. The Client
3. Guiding Conception with Research and Clinical Experience Support
4. Assessment of the Client's Problems, Goals, Strengths, and History.
5. Formulation and Treatment Plan
6. Course of Therapy
7. Therapy Monitoring and Use of Feedback Information
8. Concluding Evaluation of the Therapy's Process and Outcome
9. References
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11. Figures (optional)
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Vol 13, No 2 (2017)

Table of Contents

Case Study

Written Exposure Therapy as Step One in Reducing the Burden of PTSD: The Composite Cases of "Alex," "Bruno," and "Charles" Abstract PDF
David J. Austern 82-141
Stepped-Care Approaches to Posttraumatic Stress Disorder: Sharpening Tools for the Clinician’s Toolbox Abstract PDF
Jeffrey A. Cigrang, Alan L. Peterson 142-153
On the Implementation of Written Exposure Therapy (WET) with Veterans Diagnosed with PTSD Abstract PDF
Denise M. Sloan, Brian P. Marx 154-164
Beyond Binary Thinking: Providing Best Practice Treatment to Veterans with PTSD Abstract PDF
David J. Austern 154-172