Pilot Testing EF-CPT: A Manualized Intervention for Treatment of Trauma in Veterans

Background and purpose: Approximately 12-15% of veterans who have deployed since 2001 experience symptoms of PTSD, yet available evidence suggests that up to 50% remain resistant to therapeutic intervention to address symptoms. Less than 10% of all veterans who would benefit from intervention are estimated to have received what is considered to be evidence-based treatment for PTSD: typically a course of cognitive processing therapy (CPT) or prolonged exposure (PE) therapy, for ≥ 9 sessions. While theories abound regarding reasons for poor treatment engagement (including concerns about privacy and stigma), suggestions have been made that provision of confidential services, in financially and logistically accessible locations or in alternative treatment settings, would increase participation. This study used a manualized adaptation of the CPT model championed by the VA, which infused equine facilitated activities into face-to-face therapy sessions. The aim was to test effectiveness and feasibility of an evidence-based practice in an alternative setting.

Methods: We hypothesized improvement on all measures, low attrition, and good model fidelity in this pretest-posttest design. Instruments included the following validated measures: PTSD checklist (PCL), Trauma Related Guilt Inventory (TRGI), & Working Alliance Inventory (WAI). Additionally, the Human Animal Bond scale (HABS) was used to evaluate relationship with the horse. Veterans were seen by a single therapist for 12 sessions of individual EF-CPT. Data were sent to a research team member for analysis. Paired sample t-tests were conducted using SPSS. Twenty-seven veterans participated (mean age 51; 78% male), all with PTSD diagnosis.

Results: PCL scores improved significantly (M1=68.25, M2=35.96, p=<.001), as did TRGI scores (p=<.001 on all scales). HABS & WAI indicated good working relationship. Two individuals attended one session and did not return (both were under the age of 50); there was no other attrition (7% rate).

Conclusions and Implications: The therapist was reviewed by a research team member for fidelity; the only deviations from the manual were in temporal order of session plans, which is within the acceptable flexibility of the manual. While conclusions related to attrition require bigger numbers, this manualized intervention has promise for retention in effective treatment for military related trauma in older veterans.