Cognitive Behavioral Therapy and Psychodynamic Psychotherapy in Treating War Veterans - Research Proposal Example

Topic Effectiveness of Cognitive Behavioral Therapy vs Psychodynamic Psychotherapy in Treating War Veterans with Post Traumatic Stress Disorder: A Review of Meta-Analyses Abstract Cognitive behavioral therapy and psychodynamic psychotherapy are two prominent therapeutic approaches for the treatment of different kinds of disorders and psychological diseases. Literature review suggests contrasting views about the relative efficacy of cognitive behavioral therapy and psychodynamic psychotherapy in treating PTSD. The contrasting results of the various studies originate in the influence of a range of factors upon the results. This research is aimed at drawing comparison between the effectiveness of cognitive behavioral therapy and psychodynamic psychotherapy in the treatment of war veterans with post traumatic stress disorder. This will be achieved by a review of meta-analyses of comparisons between the efficacy of various therapeutic approaches for the treatment of PTSD. Considering the limitations of the use of meta-analytic approach for interpreting the review’s results, the level of consistency between this research’s findings and findings of other review methodologies for the support of efficacy of cognitive behavioral therapy vs the support of efficacy of psychodynamic psychotherapy for treating PTSD will be assessed. Literature Review and Problem Statement The level of efficacy of psychotherapy for more severe depression forms is an important area of investigation. The American Psychiatric Association (2000) has recommended the use of psychotherapy for less severely depressed patients. The efficacy of psychotherapy for more chronic and severe forms of Major Depressive Disorder has been addressed in several meta-analyses (Driessen et al., 2010; Cuijpers et al., 2011). Driessen et al. (2010) used meta-analysis and meta-regression to address the question of whether there is a relationship between psychological treatment outcome and pretreatment depression severity compared with control conditions and found no significant effects on the outcomes of treatment by using meta-regression to examine depression severity’s impact. Driessen et al. (2010) then carried out severity analyses within-study in order to study psychotherapy’s effect on a high-severity as well as a low-severity group. Posttreatment comparison of the psychological treatment with the control groups led the authors to determining a size favoring psychotherapy of significant effect for the group of low severity whereas a significantly larger effect for psychotherapy was determined when the same analysis was conducted over the group of high severity. This led the authors to the conclusion that treatment outcome is moderated by depression severity, “but in the reverse of what many assume: psychotherapy is more efficacious for high severity patients than for low severity patients” (Hunsley, Elliott, and Therrien, 2013). Cuijpers et al. (2011) studied psychotherapy’s effect on severe and chronic depression by carrying out a data meta-analysis from the depression-treated inpatients. They included a total of 12 RCTs in the study, 10 of which received antidepressant medication in all conditions. Psychotherapy sessions were between 6 and 47 on average and the participants included adults and older adults. The authors did not find any significant difference between the various kinds of psychotherapy. Comparison of the effects of psychotherapy with pharmacotherapy is also another active area of investigation especially among the second-generation antidepressants. A large number of studies have generally concluded that psychotherapy for depressed adults works in the post-treatment as well as does pharmacotherapy, whereas the results of psychotherapy at the follow-up have been found to be superior than those of pharmacotherapy (De Maat et al., 2006; Spielmans, Berman, & Usitalo, 2011). Clients suffering from PTSD commonly blame themselves following a traumatic event for things they could do differently but did not. The fundamental purpose of CBT is to make the clients realize that the traumatic events they experienced were not their fault. CBT for the treatment of PTSD rests on the idea that problems occur because of poor evaluation and interpretation of situations, feelings, and thoughts, and people’s indulgence in problematic acts as a result of these evaluations e.g. avoidance (Tull, 2014). Some ways in which CBT is used to treat PTSD include stress-inoculation training, exposure therapy, behavioral activation, cognitive processing therapy, and acceptance and commitment therapy. Psychodynamic psychotherapy works by working through the unconscious painful feelings to bring about change in the behavior. Psychodynamic psychotherapists achieve this by helping the patients with recognition of the defense mechanisms, explaining them the rationale for their use, and connecting with or releasing the thoughts and feelings that the client avoided previously. The effectiveness of use of psychodynamic psychotherapy for the treatment of PTSD has been less extensively studied than the effectiveness of CBT in treating PTSD (Tull, 2014). However, some research that has been conducted to explore the use of psychodynamic psychotherapy in treating PTSD has concluded with identifying a number of benefits. Psychodynamic psychotherapy has been found useful in improving the interpersonal relationships of people suffering from PTSD. Other studies have noticed a reduction in the feelings of inadequacy and hostility along with an increase in assertiveness and confidence level of the patients. Generally, psychodynamic psychotherapy has been found helpful in combating the depression and other symptoms associated with PTSD. Either of the two therapies i.e. CBT and Psychodynamic psychotherapy cannot be established as the ultimate or a better approach toward treating the patients of PTSD (Tull, 2014). The suitability of treatment approach varies from one patient to another depending upon a range of factors including age, gender, gravity of traumatic experience, and post-traumatic life experiences. Sometimes, both CBT and psychodynamic psychotherapy may be used in conjunction with each other to treat a patient of PTSD. More research needs to be conducted to study the effectiveness of psychodynamic psychotherapy for treating patients of PTSD and particularly to compare its effectiveness with that of CBT in treating the war veterans with PTSD. This research will fill this gap in the literature and identify which of the two therapeutic approaches is more useful in treating the war veterans with PTSD. Hypothesis The hypothesis of this research is that CBT is more effective in treating the war veterans suffering from PTSD as compared to psychodynamic psychotherapy. Theoretical Framework Cognitive behavioral therapy (CBT) is a kind of counseling that has been found to be the most effective of all sorts of counseling for the treatment of PTSD (US Department of Veterans Affairs, 2014; Kar, 2011). The US Department of Veterans Affairs offers two kinds of CBT for the treatment of PTSD in veterans; prolonged exposure (PE) therapy and cognitive processing therapy (CPT). The generic form of CBT involves interaction between a client and a therapist so that the therapist may help the client understand and change his/her feeling about the trauma and the circumstances that ensue. The goal is to make the client realize the role of certain thoughts in causing the stress and worsening the symptoms related to trauma. The clients frequently experience such thoughts but are often not aware of their role in the stress they experience. The therapist helps the clients replace such thoughts with more rational, lighter, and realistic thoughts. The therapist also teaches the clients how to deal with guilt, fear, and anger. On the contrary, psychodynamic approaches to the treatment of PTSD (Spermon, Darlington, and Gibney, 2010) draws upon a variety of factors that induce the symptoms of PTSD which may include but are not limited to early childhood experiences, present activities, current relationships directed at protecting themselves from the feelings and upsetting thoughts that occur because of the traumatic event. Such endeavors of the victims are referred to as ‘defense mechanisms’. “Psychodynamic approaches may help address crucial areas in the clinical presentation of PTSD and the sequelae of trauma that are not targeted by currently empirically supported treatments” (Schottenbauer et al., 2008). Unlike CBT, psychodynamic psychotherapy focuses on the unconscious mind which is the origin of upsetting urges, thoughts, and painful feelings (Tull, 2014). Despite being outside the realm of awareness, the painful feelings and thoughts still influence human behavior. They work in such indirect ways as discouraging an individual from developing relationship with someone because of a false fear that the relationship would implant painful feelings. The common element between CBT and psychodynamic psychotherapy is that both therapies are directed at inducing changes in behavior. A psychodynamic therapist may recognize the denial after several sessions from the patient regarding the level of impact of a traumatic event on his life. A common defense mechanism employed to protect an individual from something he cannot cope with is ‘disavowal’. Similarly, a therapist may notice undue blaming of the family members by the patient even though they are not at fault. Therapists may interpret such behavior of the clients as a sign of depression in the clients. People tend to share the blame with others when the guilt and anger is too massive to take alone. This is a defense mechanism termed as ‘displacement’. In both disavowal and displacement, the job of a therapist is to interpret the behavior of the patient and share it with him. This allows both to distort the unhelpful defense mechanism and have an insight into the real problem so that the client can work through the painful feelings in a more appropriate and healthy manner. Study Rationale This study will be carried out to draw a comparison between the effectiveness of CBT and psychodynamic psychotherapy in treating the war veterans suffering from PTSD. This study will have great impact both on the literature and practice of medical science and therapeutic approaches for behavioral counseling. A lot of research has been conducted to study the effect of different kinds of therapies on the patients suffering from different kinds of disorders, but there is dearth of research that compares the effectiveness of one therapeutic approach against the other. Particularly, there is possibly a gap in the research regarding discrepancy in the effectiveness of CBT and psychodynamic psychotherapy in treating war veterans with PTSD. The results of this study will provide the therapists with objective basis to choose either or both of the therapeutic approaches in a certain combination for the treatment of war veterans with PTSD. The effects will include but may not be limited to increased effectiveness of treatment approach, quicker recovery from PTSD for the war veterans, and reduced cost of treatment. The subgroup that is likely to benefit from the findings of this study the most is that of the war veterans because the research will be conducted on them. However, the findings of this study can generically be applied to all patients of PTSD particularly older adults as they share the same age-group with the war veterans. The role of marketing and creation of awareness about the appropriate intervention programs to target PTSD cannot be overemphasized. Therefore, this research will also devise ways in which the programs or interventions can be developed. The preliminary idea advocates the establishment of both online and brick-and-mortar programs of intervention to provide the patients with increased access and convenience of availing the program and to optimize their tendency to undergo such programs for the treatment of PTSD. Both online and brick-and-mortar programs will screen the applicants for the symptoms of PTSD so as to ensure that they suffer from PTSD and not some other depression disorder. The patients will be further referred to the concerned therapists for intervention. Methodology Design This research will use meta-analysis as a way to compare the efficacy of CBT with the efficacy of psychodynamic psychotherapy in the treatment of war veterans suffering from PTSD. Treatment efficacy in meta-analysis is quantified as effect size (ES) which reflects an observed effect’s magnitude in a standard measurement unit which may be correlation coefficient or standard deviation. Effect sizes will be categorized along a scale of no effect to high where the ESb0.2, 0.2VESb0.5, 0.5VESb0.8, and ESz0.8 will correspond to no effect, low effect, medium effect, and high effect respectively (Cohen, 1988). Meta-analysis derives its strength from the use of a standardized unit in order to draw comparisons of the studies’ outcomes that have reached them using different methodologies. Meta-analysis is also suitable to draw empirical evidence about the relative effectiveness of CBT and psychodynamic psychotherapy in treating the war veterans suffering from PTSD because it averages out the effect sizes across the various research studies and their comparisons, which in effect minimizes the extraneous factors’ influence along with increasing the effective sample size. This makes it possible for the researchers to evaluate a treatment’s efficacy for a certain disorder or disease more precisely. Inclusion Criteria The first objective of this study will be to identify the meta-analyses that have been published and that have reviewed outcome studies on CBT as well as psychodynamic psychotherapy. Methodologically rigorous and most extensive meta-analysis will be selected in case of multiple meta-analyses for PTSD. Methodological strengths will be considered as inclusion of moderator variables, analysis of heterogeneity of the outliers and effect sizes, effect sizes’ weighting with sample-size, and randomized clinical trials’ inclusion. Recruitment and Sampling The meta-analyses will be identified with a computer databases’ search including a search of Medline and PsycINFO Eric with the help of key words ‘cognitive behavioral therapy’, ‘psychodynamic psychotherapy’ and ‘PTSD’. The selected book chapters and articles will be reviewed. Texts of these reviews will serve as the places to identify additional meta-analyses. The final size of the sample will be determined accordingly. These meta-analyses will include multiple comparisons and disorders. Occasionally, there may be overlap of the chosen meta-analyses in terms of the reviewed studies in which case, pertinent studies will be included from just one meta-analysis. Each meta-analysis will be reviewed in reference to the distinct comparisons it makes. Instrumentation The U3 scores will also be reported for each comparison in order to facilitate the interpretation. U3 indicates the scores’ percentage in the group with lower means that will be exceeded in the higher-meaned group by the average score (Cohen, 1988). It is important to explain the relationship between U3 and ES while interpreting the meta-analyses’ findings. For instance, a 0.0 ES will reflect no effect of treatment. Its conversion into a 50 per cent U3 will indicate that both the CT patient and the member of the control group did equally well. Conclusion This research will assess the relative efficacy of CBT and psychodynamic psychotherapy in treating war veterans suffering from PTSD. This will be achieved through a review of meta-analyses of the past studies that have compared different therapeutic approaches for efficacy in different disorders. Further research should be done to compare the relative efficacy of CBT and psychodynamic psychotherapy in other mental disorders and illnesses. This will provide a suitable ground for the comparison of the results of this study with other studies so as to establish whether either of the two therapeutic approaches always outweighs the other or the difference is subject to a host of factors. Results produced by this study will be useful for selecting the most suitable approach for treating PTSD in war veterans in terms of cost effectiveness, efficiency, and quality of treatment. This research will make huge contribution both to the literature of medical sciences and therapeutic approaches for the treatment of psychological disorders and illnesses and to the practice in the industry. References: American Psychiatric Association (2000). Practice guidelines for the treatment of patients with major depressive disorder (revision). American Journal of Psychiatry. 157(4), 1-45. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ7 Erlbaum. Cuijpers, P., Clignet, F., van Meijel, B., van Straten, A., Li, J., & Andersson, G. (2011). Psychological treatment of depression in inpatients: A systematic review and meta-analysis. Clinical Psychology Review. 31, 353-360. De Maat, S., Dekker, J., Schoevers, R., & De Jonghe, F. (2006). Relative efficacy of psychotherapy and pharmacotherapy in the treatment of depression: A metaanalysis. Psychotherapy Research. 16, 566-578. Driessen, E., Cuijpers, P., Hollon, S. D., & Dekker, J. J. M. (2010). Does pretreatment severity moderate the efficacy of psychological treatment of adult outpatient depression? A meta-analysis. Journal of Consulting and Clinical Psychology. 78, 668-680. Hunsley, J., Elliott, K., and Therrien, Z. (2013). The Efficacy and Effectiveness of Psychological Treatments. The Canadian Psychological Association. Retrieved from http://www.cpa.ca/docs/File/Practice/TheEfficacyAndEffectivenessOfPsychologicalTreatments_web.pdf. Kar, N. (2011). Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: a review. Neuropsychiatr Dis Treat. 7, 167-181. Schottenbauer, M. A. et al. (2008). Contributions of Psychodynamic Approaches to Treatment of PTSD and Trauma: A Review of the Empirical Treatment and Psychopathology Literature. 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