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. Author manuscript; available in PMC: 2020 Dec 1.
Published in final edited form as: J Trauma Stress. 2019 Nov 19;32(6):927–935. doi: 10.1002/jts.22447

Changes in Coping and Negative Cognitions as Mechanisms of Change in Online Treatment for Rape-Related Posttraumatic Stress Disorder

Heather Littleton 1, Amie Grills 2
PMCID: PMC6938536  NIHMSID: NIHMS1047986  PMID: 31742796

Abstract

Cognitive behavioral therapy (CBT)–based interventions, including those administered via telepsychology, represent efficacious posttraumatic stress disorder (PTSD) treatments. Despite demonstrated efficacy, limited research has examined mechanisms of change for CBT. We examined trauma-related cognitions and coping as treatment mechanisms among 46 women who completed a randomized clinical trial of a CBT-based, telepsychology-delivered interactive program for rape survivors. The results indicated that both the interactive program, d = 1.5, and the active control condition, a psychoeducational website, d = 1.4, resulted in large reductions in posttest PTSD symptoms. Analysis of residual gain scores showed that reductions in the three types of assessed trauma-related cognitions were strongly related to reductions in PTSD symptoms among women assigned to the interactive program, rs = .60–.79, but only weakly related to symptom reduction among those assigned to active control, rs = .06–.31. The results also suggest that increases in trauma-related approach coping were weakly related to reductions in PTSD symptoms among participants in the interactive program, rs = −.16 and −.17, but, conversely, decreases in trauma-related approach coping were weakly related to reductions in PTSD symptoms among those in the active control group, rs = .07 and .28. Reductions in avoidance coping were modestly related to reductions in PTSD symptoms among women in the interactive program, rs = .38 and .38, but unrelated to changes in PTSD symptoms among those assigned to the active control, rs = .03 and .05. Implications for future work examining mechanisms of change for PTSD treatments are discussed.

Trauma-focused cognitive behavioral therapies (CBTs) represent well-established, efficacious treatment options for posttraumatic stress disorder (PTSD; Cusack et al., 2016; Watts et al., 2013). These treatments generally include some combination of restructuring negative trauma-related cognitions and systematic exposure to avoided trauma reminders and trauma memories. A growing body of research also supports the efficacy of CBT-based interventions for PTSD that are delivered via telepsychology, such as self-help interventions as well as therapist-facilitated interventions delivered synchronously (e.g., via video chat) or asynchronously (e.g., via e-mail or asynchronous message; Bolton, & Dorystn, 2015; Kuester, Niemeyer, & Knaevelsrud, 2016). Despite the well-established nature of these interventions, much less research has examined the mechanisms of change of these treatments (Zalta, 2015).

One possible mechanism of change for trauma-focused CBT treatments is changes in negative trauma-related cognitions. Models of PTSD development underlying several trauma-focused CBT treatments argue that such negative cognitions play a central role in the maintenance and exacerbation of trauma-related symptomology. For example, the social cognitive model developed by Resick and Schnicke (1992) argues that maladaptive attempts to reconcile the traumatic experience with existing belief structures, termed “schemas,” serve to maintain PTSD symptomology. Specifically, this model posits that both attempts to assimilate (“fit”) the trauma into existing schemas, such as by minimizing the severity of the trauma or engaging in inappropriate self-blame, as well as attempts to accommodate the trauma via extreme schema changes (“overaccommodation”) serve to maintain and exacerbate symptoms. This model serves as the basis for cognitive processing therapy (CPT), a trauma-focused CBT treatment that targets both maladaptive assimilation (e.g., unwarranted self-blame or guilt related to the trauma) and overaccommodation (e.g., extreme negative beliefs about the trustworthiness of others, poor self-image as a result of the trauma) via cognitive restructuring. Similarly, the emotional processing model of PTSD developed by Foa and Rothbaum (1998) posits that negative cognitions about the world (e.g., “The world is completely dangerous”) and one’s ability to manage stress (e.g., “I cannot handle any stress”) lead to the development and maintenance of PTSD. This emotional processing model serves as the theoretical basis for prolonged exposure (PE) therapy, a trauma-focused CBT treatment that seeks to correct these negative cognitions via systematic exposure to avoided trauma reminders and memories.

Given that trauma-focused CBT treatments are theorized to produce change via altering negative trauma-related cognitions, it is not surprising that much of the extant research on treatment mechanisms for PTSD has focused on trauma-related cognitions. Multiple studies support that CBT-based treatments result in reductions in adherence to negative trauma-related cognitions (Brown, Belli, Asnaani, & Foa, 2018), with the most commonly assessed trauma-related cognitions being negative beliefs about the self (e.g., “I am a weak person”), negative beliefs about other people (e.g., “People can’t be trusted”), and self-blame for the trauma (e.g., “The event happened because of the way I acted”; Foa, Ehlers, Clark, Tolin, & Orsillo, 1999). A much smaller number of studies have examined changes in trauma-related cognitions as a mechanism of change via correlation analyses or mediation analyses, with results of these studies generally supporting the role of trauma-related cognitions as a mechanism of CBT treatment (Brown et al., 2018). However, of note, these studies have frequently been limited by a reliance on self-report assessment of both PTSD and cognitions, and most have not utilized analytic techniques to address issues related to estimating change when using raw scores or percent change scores (Steketee & Chambless, 1992). Additionally, only two studies have examined the impact of telepsychology interventions on trauma-related cognitions, and neither study examined the extent to which changes in cognitions predicted changes in PTSD (Brown et al., 2018). Thus, there remains a need for further research examining trauma-related cognitions as a mechanism of change in CBT for PTSD, particularly as a treatment mechanism in interventions delivered via telepsychology. Work in this area is necessary to (a) establish whether negative cognitions can be altered via telepsychology and (b) evaluate whether interventions delivered using telepsychology lead to reductions in PTSD symptomology via similar mechanisms as do face-to-face psychotherapy interventions.

Another potential mechanism of change for CBT-based PTSD treatments is changes in trauma-related coping. Coping refers to effortful strategies utilized to manage stressful events, which are events that “undermine stability” and/or interfere with an individual’s ability to engage in his or her usual activities (e.g., work, leisure activities; Snyder & Pulvers, 2001, p. 4). In particular, reliance on avoidance coping strategies (e.g., withdrawing from others, disengaging from thoughts and feelings) are posited to be key in maintaining PTSD symptomology by interfering with cognitive and emotional processing of the traumatic experience as well as by interfering with new learning with regards to whether situations are safe or risky for experiencing further trauma (Badour, Blonigen, Boden, Feldner, & Bonn-Miller, 2012; Foa & Kozak, 1986; Resick & Schnicke, 1993). These avoidance coping strategies can be thought of as the converse of approach coping, which involves using active strategies to either directly address the stressful event (e.g., engaging in problem solving, seeking help from others) or to manage one’s thoughts and emotions related to the stressful event (e.g., expressing one’s emotions, seeking emotional support; Snyder & Pulvers, 2001). Supporting the potential importance of avoidance coping in maintenance of symptomology, research has consistently found a clear positive correlation between reliance on avoidance coping strategies and PTSD symptoms among individuals who have experienced multiple types of trauma (Littleton, Horsley, John, & Nelson, 2007).

Trauma-focused CBT treatments frequently utilize several techniques aimed at reducing reliance on avoidance coping, such as engaging in planned exposures to avoided trauma cues, and increasing adaptive approach coping, such as encouraging seeking social support, assisting with active problem solving, and facilitating cognitive restructuring. However, little research has investigated changes in trauma-related coping following CBT for PTSD. Of the extant research, one study of veterans with comorbid PTSD and substance use disorder found that approach coping increased and avoidance coping decreased over the course of the Seeking Safety treatment program. Further, PTSD symptoms and avoidance coping scores were correlated at posttest and follow-up (Boden et al., 2014). Conversely, among a large sample of veterans with treatment-resistant PTSD, avoidance coping at discharge from inpatient treatment did not predict PTSD symptomology at follow-up, whereas PTSD symptoms at discharge predicted avoidance coping at follow-up (Badour et al., 2012). Thus, there is only limited research on changes in coping as a mechanism of change in CBT for PTSD, and extant research has yielded mixed findings.

The current study sought to address some of these gaps in the literature by investigating changes in both trauma-related cognitions and trauma-related coping as predictors of changes in interviewer-assessed PTSD symptoms among a sample of rape survivors who completed a randomized clinical trial (RCT) of an online, therapist-facilitated, modular CBT program (Littleton, Grills, Schoemann, Drum, & Dodd, 2016). Based on prior research, we hypothesized that reductions in negative trauma-related cognitions and avoidance coping would be associated with reductions in PTSD symptoms following treatment for participants who were assigned to the therapist-facilitated CBT program. Given the associations between trauma-related cognitions and coping and PTSD symptomology, we also predicted that reductions in trauma-related cognitions and avoidance coping would be associated with reductions in PTSD symptomology among individuals assigned to a psychoeducational website that served as an active control condition. However, given that trauma-related cognitions and coping were not as extensively targeted in the active control condition, we predicted that these relations would be weaker than those found among individuals assigned to the interactive program. Finally, as the therapist-facilitated CBT program targeted both emotion and problem-focused coping, we examined changes in both forms of coping as predictors of reductions in PTSD. However, we made no specific hypotheses regarding differences in the strength of these association for each type of coping. Similarly, we made no hypotheses with regards to changes in approach coping and reductions in PTSD symptomology.

Method

Participants

Participants were 46 women who participated in an RCT of the efficacy of an online intervention for rape survivors with PTSD. For the current study, analyses were restricted from the full sample of 87 individuals randomized to those participants who provided pre and posttest self-report and interview data (n = 55 overall retained at posttest). Participants’ mean age was 22.5 years (SD = 6.0; range: 18–42); they were asked to indicate all ethnic and racial identities with which they identified, with 52.2% identifying as White/European American, 26.1% as Black/African American, 17.4% as Asian/Pacific Islander, 6.5% as Hispanic/Latina, and 4.2% as multiethnic. Most participants were in their first or second year of college (n = 24, 52.2%), and the remainder were in their third year (n = 9, 19.6%), fourth year (n = 11, 23.9%), or were masters-level students (n = 2, 4.2%). A total of 54.4% participants (n = 25) had experienced other interpersonal violence, with childhood sexual abuse (n = 15, 32.6%), childhood physical abuse (n = 13, 28.2%), and intimate partner violence (n = 7, 15.2%) the most commonly reported. Prior analyses supported no differences in demographics; child abuse history; and pretreatment PTSD, depression, or general anxiety between individuals who were retained at posttesting and those who dropped out or who never initiated the program (Littleton et al., 2016). Likewise, in the current study, there were no significant differences in age, ethnic/racial minority status, other interpersonal violence history, PTSD symptoms, trauma-related cognitions, or trauma-related coping between participants included in the analyses and those who were excluded.

Procedure

Women with current rape-related PTSD who were enrolled as a student at one of four universities or community colleges were recruited, via advertisements, to participate in an online program for women who were distressed about an unwanted sexual experience. Participants were screened by telephone for eligibility; this screening included the administration of an assessment of current rape-related PTSD symptomology. Inclusion criteria included age between 18 and 50 years; meeting criteria for PTSD, per the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-1V), in connection to a completed rape experience that occurred after 14 years of age; and current enrollment as an undergraduate or graduate student at one of the four participating universities or community colleges. Exclusion criteria included current psychotherapy, lack of stability on psychotropic medication, active suicidality as determined by an interview version of the Scale for Suicidal Ideation (Beck, Kovacs, & Weissman, 1979), or fulfilment of DSM-IV criteria for current substance dependence as assessed with the Substance Use Disorder module of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-IV; First, Spitzer, Gibbon, & Williams, 2002). In addition, all participants had to have regular access to a computer as well as a telephone number at which they could reliably be reached. A total of 150 individuals were screened for eligibility, with the most common reasons for exclusion being not meeting diagnostic criteria for PTSD (n = 20, 31.3%), current psychotherapy (n = 17, 26.6%), and that the individual had either experienced a completed rape in the context of ongoing childhood sexual abuse only or had not experienced a completed rape in adolescence or adulthood (n = 10, 15.6%). The remaining excluded individuals (n = 12) were excluded for other reasons, including current substance dependence, lack of stability on psychotropic medication, current suicidality, and appearing to be in a high level of acute distress. Finally, four individuals (6.3%) declined to participate after completing the consent or screening.

Eligible participants completed a set of online self-report questionnaires. After completing these questionnaires, they were randomized via computerized coin flip to either the online therapist-facilitated CBT-based interactive program or a self-help psychoeducational website (i.e., the active control; see Littleton et al., 2016). The study was approved by the institutional review boards of all four U.S. institutions from which participants were recruited: Boston University, East Carolina University, Pitt Community College, and University of Houston.

The therapist-facilitated CBT-based interactive program consisted of nine program modules, which were completed sequentially. Modules 1–3 focused on psychoeducation about rape and PTSD, instruction in use of relaxation and grounding, and instruction in strategies to increase goal setting and use of approach coping. Modules 4 and 5 introduced the cognitive model and cognitive restructuring. Finally, Modules 6–9 utilized a number of cognitive and behavioral strategies to address problems commonly experienced by rape survivors, including self-blame, difficulties with trust and intimacy, and low self-worth. Each module included multimedia content and interactive exercises, to which a program therapist provided asynchronous written and video-recorded feedback to participants’ written responses. The modules were designed to be completed in 30 min to 1 hr, depending on the number of interactive exercises within the module participants chose to complete. Program therapists were either the authors; licensed, doctoral-level psychologists; or a postdoctoral fellow who was supervised by the authors. A total of 27.3% (n = 6) of the 22 participants assigned to the interactive program completed it, with 81.8% (n = 18) completing at least some of the content related to cognitive restructuring. The remaining participants (n = 4) completed through Module 3.

The psychoeducational active control website consisted of the written content of the first three modules of the interactive program (i.e., psychoeducation, relaxation/grounding, and coping). Participants assigned to the psychoeducational active control website were given access to all the program content and instructed to utilize the program however they wished. The website did not contain multimedia content or any interactive exercises nor did it include feedback from a therapist or study staff.

Participants in both conditions completed brief telephone check-ins with a clinically trained doctoral student every other week while completing the intervention or while accessing the website. Check-ins briefly assessed current distress, suicidality, substance use, and program usage, and they took, on average, approximately 5 min. Participants varied in their completion of these check-in calls, completing an average of 3.8 check-ins (SD = 1.87, range: 0–7). At 14 weeks after enrolling, participants were contacted via email and telephone or text message to complete another interview assessment of their PTSD symptoms along with a second online survey.

Measures

Rape-related PTSD symptoms.

The PTSD Symptom Scale–Interview (PSS-I; Foa, Riggs, Dancu, & Rothbaum, 1993) was administered at pre- and postintervention to assess current rape-related PTSD symptoms. The PSS-I consists of 17 items designed to map on to the DSM-IV criteria for the diagnosis of PTSD (Foa et al., 1993). For each item, participants were asked to use their rape experience, or worst rape experience if they had experienced multiple rapes, as the reference traumatic event when indicating how much they had been bothered by each symptom in the past month. Overall, scores can range from 0 to 51, and a cutoff score of 14 for probable PTSD is recommended (Coffey, Gudmundsdottir, Beck, Palyo, & Miller, 2006). Prior research has supported the measure’s internal consistency, test–retest reliability, and concurrent validity with other measures of PTSD symptomology (Foa et al., 1993). In the current sample, Cronbach’s alpha values ranged from .70 to .83 across administrations. The PSS-I was administered by study staff, most often a trained doctoral student. Due to the nature of the posttest assessment in which participants also answered questions about their impressions of the online intervention to which they had been assigned, interviewers were not blind to intervention condition.

Trauma-related coping.

The 72-item Coping Strategies Inventory (CSI; Tobin, Holroyd, Reynolds, & Wigal, 1989) was administered to assess participants’ trauma-related coping. The CSI is divided into the domains of approach (i.e., engagement) and avoidance (i.e., disengagement) coping. The four subscales are: Problem Engagement (problem solving and cognitive restructuring), Emotion Engagement (social support seeking and emotional expression), Problem Disengagement (problem avoidance and wishful thinking), and Emotion Disengagement (social withdrawal and self-criticism). For each item, participants were asked to indicate how often they used the strategy in handling their experience with unwanted sex in the past month on a 5-point rating scale ranging from 1 (not at all) to 5 (very much). Cronbach’s alpha values of these scales have been reported to range from .81 to .92 (Tobin, 2001) and likewise ranged from .81 to .92 across assessments in the current study.

Trauma-related cognitions.

The 33-item Posttraumatic Cognitions Inventory (PTCI; Foa et al., 1999) was administered to assess negative trauma-related cognitions. The PTCI has three subscales: Negative Cognitions about the World and People (“The world is a dangerous place”), Negative Cognitions About the Self (“I am inadequate”), and Self-Blame (“The event happened to me because of the sort of person that I am”). Participants indicated how much they agreed with each statement, using their experience with unwanted sex as a reference event, on a 7-point Likert scale ranging from 1 (totally disagree) to 7 (totally agree). Prior research has supported the measure’s internal consistency, test–retest reliability, and convergent validity (Foa et al., 1999). In the current study, Cronbach’s alpha values for the subscales across assessments ranged from .80 to .96.

Data Analysis

To evaluate changes in PTSD, coping, and trauma-related cognitions from pretest to posttest, Cohen’s d values were calculated using the correction for dependence among means in repeated measures designs recommended by Morris and DeShon (2002). Specifically, this procedure corrects for the inflation in Cohen’s d values that occurs due to a high positive correlation between pre- and posttest scores, in order to allow for direct comparisons of effect sizes across samples which vary in the extent to which pre- and posttest scores are positively correlated. For the obtained value, a Cohen’s d of 0.80 or larger represents a large effect, 0.50–0.79 represents a medium effect, and 0.20–0.49 represents a small effect.

To evaluate the extent to which changes in coping and trauma-related cognitions were related to improvements in PTSD symptoms posttreatment, residual gain scores were calculated. Calculating residual gain scores involved first converting raw scores to z scores. The z-transformed pretest score was then multiplied by the correlation between the pre- and posttest score, and this value was then subtracted from the z-transformed posttest score (Steketee & Chambless, 1992). Correlations between residual gain scores were than calculated to examine the extent to which changes in coping and trauma-related cognitions were correlated with reductions in PTSD symptoms (Foa & Rauch, 2004; Steketee & Chambless, 1992). Using residual gain scores addressed problems with over- or underestimation of change associated with use of raw change scores or percent change scores (Steketee & Chambless, 1992). Further, a Monte Carlo simulation study supported the statistical power of this method under conditions of adequate reliability of measures and low-to-moderate levels of imbalance in baseline scores across conditions, as in the current investigation (Kisbu-Sakarya, MacKinnon, & Aiken, 2013). Of note, given the sample size for these obtained correlations, power to identify statistically significant associations was adequate (73%–84%) for large associations, r = .50, but was low (36%–42%) for medium-sized associations, r = .30.

Results

Participants’ scores on the PSS-I, CSI, and PTCI at pre- and posttest, stratified by intervention condition, are summarized in Table 1. Completing both intervention programs led to large reductions in PTSD symptoms as well as medium-sized reductions in trauma-related cognitions. Regarding changes in trauma-related coping, participants in both conditions reported medium-sized reductions in problem-focused avoidance coping and large reductions in emotion-focused avoidance coping. Additionally, participants assigned to the interactive program reported medium-sized increases in use of both forms of approach coping.

Table 1.

Participant scores on the PSS-I, PTCI, and CSI at pre- and post-assessment stratified by intervention condition

Interactive Program Psycho-education
M (SD) Range n d M (SD) Range n d
PSS-I
  Pre 25.18 (6.43) 14–35 22 1.5 23.04 (7.87) 11–43 24 1.4
  Post 11.00 (6.03) 0–22 20 10.88 (8.94) 0–39 24
PTCI (self)
  Pre 73.27 (27.00) 25–106 22 0.5 61.96 (29.41) 22–126 24 0.5
  Post 58.32 (27.41) 21–106 19 52.65 (27.51) 21–104 23
PTCI (world)
  Pre 36.18 (8.08) 21–48 22 0.6 36.75 (6.99) 21–49 24 0.6
  Post 30.26 (10.39) 13–45 19 30.25 (11.38) 7–49 24
PTCI (blame)
  Pre 20.00 (6.68) 5–28 22 0.4 19.75 (6.78) 10–33 24 1.1
  Post 16.90 (8.12) 5–33 21 14.92 (8.94) 5–29 24
CSI (problem engagement)
  Pre 51.33 (12.25) 33–74 21 −0.4 47.00 (14.00) 20–78 24 0.1
  Post 54.50 (9.10) 41–73 18 46.21 (12.74) 18–69 24
CSI (emotion engagement)
  Pre 50.24 (13.74) 22–72 21 −0.7 47.35 (13.15) 26–72 20 0.0
  Post 58.14 (11.55) 41–78 21 47.09 (15.21) 18–69 24
CSI (problem disengagement)
  Pre 59.30 (9.96) 45–73 20 0.6 52.59 (14.30) 21–74 22 0.5
  Post 52.53 (9.19) 33–64 19 47.33 (15.02) 19–71 23
CSI (emotion disengagement)
  Pre 57.55 (10.47) 43–79 22 0.9 51.46 (14.58) 27–78 24 0.9
  Post 47.90 (10.67) 29–69 19 41.57 (13.45) 18–66 23
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Note. PSS-I: PTSD Symptom Scale Interview; PTCI: Posttraumatic Cognitions Inventory; CSI: Coping Strategies Inventory. d = Cohen’s d with Morris and DeShon (2002) correction for dependence among means.

Examining the correlations among residual gain scores indicated that reductions in all three types of trauma-related cognitions were significantly related to reductions in PTSD symptoms among individuals assigned to the interactive program, rs= .60–.79, p < .001–p = .007 (see Table 2). In contrast, reductions in trauma-related cognitions were either unrelated or moderately related to reductions in PTSD symptoms among individuals assigned to the psychoeducational active control website, rs = .06–.31, ps = .213–.796. As far as trauma-related coping, increases in approach coping were weakly related to reductions in PTSD symptoms among individuals assigned to the interactive program, r = −.16, p = .528; and r = −.17, p = .518s. In contrast, for individuals assigned to the psychoeducational active control website, decreases in problem-focused approach coping were moderately related to reductions in PTSD symptoms, r = .28, p = .178, but changes in emotion-focused approach coping was largely unrelated to changes in PTSD symptoms, r = .07, p = .778. For individuals assigned to the interactive program, reductions in avoidance coping were moderately associated with reductions in PTSD symptoms, rs = .38 and r = .38, ps = .123 and .166, whereas there was no association between changes in avoidance coping and changes in PTSD symptoms among those assigned to the psychoeducational active control website, r = .03, p =.891; and r = .05, p = .817.

Table 2.

Correlations Between Residual Gain Scores on Posttraumatic Stress Disorder (PTSD) Symptoms, Posttraumatic Cognitions, and Coping Strategies at Pre- and Postassessment, Stratified by Intervention Condition

2 3 4 5 6 7 8
Interactive program
1. PSS-I .79* .70* .60* −.17 −.16 .38 .38
2. PTCI–Self -- .78* .70* −.32 −.33 .18 .43
3. PTCI–World -- -- .75* −.24 −.57* .20 .55*
4. PTCI–Blame -- -- -- −.11 −.12 .56* .43
5. CSI–Problem Engagement -- -- -- -- .75* .10 .21
6. CSI–Emotion Engagement -- -- -- -- -- .17 −.09
7. CSI–Problem Disengagement -- -- -- -- -- -- .49
8. CSI–Emotion Disengagement -- -- -- -- -- -- --
Control
1. PSS-I .06 .31 .26 .28 .07 .03 .05
2. PTCI–Self -- .46* .69* .12 −.15 .11 .32
3. PTCI–World -- -- .39 .07 −.36 −.04 .03
4. PTCI–Blame -- -- -- .22 −.07 .21 .24
5. CSI–Problem Engagement -- -- -- -- .45 .56* .55*
6. CSI–Emotion Engagement -- -- -- -- -- .27 .10
7. CSI–Problem Disengagement -- -- -- -- -- -- .61*
8. CSI–Emotion Disengagement -- -- -- -- -- -- --
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Note. Holm method applied. PTSD = posttraumatic stress disorder; PSS-I = PTSD Symptom Scale–Interview; PTCI = Posttraumatic Cognitions Inventory; CSI = Coping Strategies Inventory.

*

p < .05.

Discussion

The results of the current study add to the growing literature on mechanisms of change in CBT-based PTSD treatment. Notably, as reported in prior research (Brown et al., 2018), the present results strongly support that changes in trauma-related cognitions, a theoretically relevant target of CBT interventions, were associated with improvements in PTSD symptomology for individuals who completed the interactive program. Thus, the results affirm that not only do trauma-focused CBT interventions lead to reductions in trauma-focused cognitions but that the degree of change in these cognitions following treatment is strongly associated with the degree of change in PTSD symptomology. Further, supporting the transportability of trauma-focused CBT treatments to telepsychology, reductions in both cognitions and PTSD symptoms occurred among women with rape-related PTSD who completed treatment online.

The present results also suggested that changes in trauma-related coping may serve as a mechanism of change for trauma-focused CBT. Although the size of the correlation between gain scores was in the moderate range, reductions in avoidance coping were associated with reductions in PTSD symptomology from pre- to posttreatment. Further, women who completed the interactive program experienced medium-sized reductions in problem-focused avoidance coping (i.e., actively avoiding thinking about their rape experience) and large reductions in emotion-focused avoidance coping (i.e., withdrawing from others). Conversely, although women who completed the interactive program experienced medium-sized increases in their use of trauma-focused approach coping strategies, increases in approach coping were weakly related to decreases in PTSD symptomology from pre- to posttreatment. Thus, the results overall provided some support for the role of changes in trauma-related avoidance coping as a possible mechanism of change but to a lesser extent than for trauma-related cognitions.

Differences in the current findings as compared to prior studies that have examined coping as a treatment mechanism likely relate, at least in part, to differences in treatments and populations between the current study and prior studies. For example, as compared to the current study, Boden and colleagues (2014) found smaller changes in coping following Seeking Safety treatment for veterans with comorbid substance use disorder and PTSD. Additionally, approach coping was not associated with PTSD severity over time. Notably, trauma- and substance use–related coping was targeted extensively in the Seeking Safety treatment participants received. One possibility is that the high level of impairment experienced by participants in the study by Boden and colleagues (2014) served to reduce the impact of the treatment on trauma-focused coping. Participants in the study by Badour and colleagues (2012) were receiving inpatient treatment for treatment-resistant PTSD; thus, they were highly impaired due to their PTSD symptoms. Additionally, the extent to which the treatment used in the Badour and colleagues’ (2012) study targeted trauma-focused coping is not described. In contrast, the interactive program evaluated in the current study targeted coping throughout the intervention. For example, Module 3 focused on helping participants identify helpful and not helpful coping strategies they currently use and assisted them in engaging in more adaptive coping, such as seeking help from others or making an action plan. Later modules focused on using various cognitive and behavioral strategies to help participants evaluate and confront distressing thoughts and beliefs related to their rape experience and encouraged participants to seek support from others.

Like the interactive program, individuals who completed the psychoeducational website–based program also experienced large reductions in PTSD symptoms and medium-to-large–sized reductions in trauma-related cognitions. This is consistent with results reported in prior studies of self-help interventions for PTSD, which have found that completion of these programs is associated with large reductions in PTSD symptoms if such programs also include some form of check-in or intervention to encourage engagement with the program (Kuester et al., 2016). Additionally, similar to the findings of the current study, prior research has found that online interactive programs for PTSD produce similar-sized effects as active control conditions (Kuester et al., 2016). It is also worth noting that prior analyses using the current dataset supported an interaction between pretreatment PTSD and program condition such that individuals with lower levels of pretreatment PTSD who were assigned to the psychoeducational website had larger reductions in PTSD posttreatment, whereas those with higher levels of pretreatment PTSD assigned to the interactive program showed larger reductions in PTSD posttreatment (Littleton et al., 2016). Thus, the present findings indicate that the psychoeducational website was an efficacious treatment option, particularly for individuals with more moderate levels of PTSD symptomology. In contrast, participants with more severe symptomology may need a more intensive treatment that includes some form of interaction and support from a therapist.

Interestingly, although individuals assigned to the psychoeducational website experienced reductions in both PTSD symptoms and trauma-related cognitions, changes in PTSD symptoms were only moderately associated with changes in cognitions at posttreatment and were unrelated to changes in self-cognitions. Thus, there was only weak evidence for the role of trauma-related cognitions as a mechanism of change for the psychoeducational website. Similarly, only reductions in problem-focused avoidance coping were moderately related to reductions in PTSD symptoms, with changes in the other types of coping not related to changes in PTSD symptoms. It is also worth noting that individuals did not experience changes in their trauma-related approach coping from pre- to postintervention. This suggests that there were other mechanisms of change for the psychoeducational website. As the focus of much of the intervention content was on instruction in stress management and emotion regulation skills, it is possible that these may have been key mechanisms of change. Provision of instruction in these skills may also have served to improve participants’ self-efficacy to actively manage their symptoms. This may explain the moderate association found with reductions in problem avoidance coping and changes in PTSD symptoms. Another possibility is that the psychoeducational website led to increased informal help and support seeking. Indeed, anecdotally, a number of participants reported engaging in disclosure to informal support sources while completing the self-help program. Relatedly, many participants reported during posttesting that they found the support they received from program staff to be one of the most helpful aspects of their participation.

Strengths and limitations of the current study should be noted. Strengths included the utilization of an interviewer-administered measure of PTSD, use of residual gain scores to evaluate mechanisms of change, and examination of mechanisms of change among individuals who received a CBT-focused treatment and those who received an active control intervention. Limitations included fairly low rates of completion of all posttest measures; sole reliance on self-report assessments of coping and trauma-related cognitions; and use of only two assessments, which prevented modeling of changes over multiple time points. Indeed, as assessments were completed at pre- and posttesting, temporal precedence could not be established with regards to whether changes in cognitions and coping or PTSD symptoms occurred first. Thus, it is possible that changes in PTSD preceded changes in cognitions and coping or that both occurred simultaneously. However, the differential relations between both coping and cognitions and PTSD symptoms across conditions suggests the possibility that changes in cognitions and coping preceded changes in PTSD symptoms for participants in the interactive program but not those in the active control condition; however, replications of these findings using multiple assessments of these constructs during treatment are needed. Additionally, although participants were racially and ethnically diverse and many had histories of other forms of interpersonal trauma, the findings may not generalize to other populations, such as older adults who may be less comfortable completing treatment online and individuals with lower levels of literacy. Finally, given the small sample size, the stability of the obtained correlations is low, supporting a need for replication in larger samples. Relatedly, the small sample size meant that we had low power to detect medium and small effects. Thus, the study could not establish via traditional significance testing whether the evaluated constructs (trauma-related coping and trauma-related cognitions) had a medium- or small-sized association with reductions in PTSD symptomology.

Bearing these limitations in mind, the present findings support the likely importance of both changes in trauma-related cognitions and trauma-related avoidance coping as possible mechanisms of change for CBT for PTSD. Thus, future research should continue to evaluate these constructs as mechanisms of change. Particularly, future research should utilize multiple assessments of these constructs throughout treatment to establish the temporal precedence of changes in coping and cognitions. Future research should also employ larger sample sizes to ensure adequate power to detect medium-sized effects. Further, findings support that trauma-related cognitions and coping can be successfully targeted in telepsychology-based interventions and that telepsychology-based treatments can result in substantial reductions in PTSD symptomology. Additionally, the results support that non–CBT-based supportive interventions delivered via telepsychology can be an efficacious option for some individuals with PTSD, but these interventions likely reduce PTSD symptomology via alternative mechanisms as compared to CBT. Future work should focus on the evaluation of possible mechanisms of change for self-help programs, including increased stress management skills, increased coping self-efficacy, and increased disclosure and support seeking. Further research should also focus on evaluating which type of intervention is most likely to be efficacious for individuals based on factors such as comorbidity, prior trauma history, and severity of PTSD symptomology. Work in these areas is likely to significantly advance the field’s understanding of how PTSD treatments lead to reductions in symptomology and to guide treatment selection and further innovation.

Acknowledgments

This research was supported by the National Institute of Mental Health (1R34MH085118).

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