A review of Vogt, Kumar & Lee’s article ‘Examining Functioning and Wellbeing Outcomes in PTSD Outcome Research. PTSD Research Quarterly 34(3)

CPT is a treatment for PTSD and as such, the PCL-5 is the primary outcome measure. Clinicians also frequently include a measure of depression to monitor improvements in these symptoms, as whilst CPT does not directly target depression, for many participants, clinically significant improvements are noted. 

Clients frequently subjectively report feeling lighter, doing more and increasing their participation in activities of daily living post treatment. However, this is not routinely objectively measured.  

It is important to consider the focus of functional impairment and wellbeing measures. By definition, the former tends to limit attention to the negative end of the spectrum from very to not at all impaired, whereas wellbeing measures mostly capture the broader range of experience from poor to excellent. However, the term wellbeing is used very broadly and can include general measures of overall life circumstances such as happiness/positive experiences, together with domain-specific items such as health, social, financial and vocational options. The authors argue that it is important to consider both overall and domain-specific aspects when evaluating wellbeing.  

When considering wellbeing outcomes in the PTSD literature, the majority is provided via veteran studies. Much of this research focused on the functional impairment associated with PTSD with findings revealing negative implications of PTSD for multiple aspects of functioning and well-being. This highlights the need to evaluate not only PTSD symptom severity but also whether improvement in or return to premorbid levels of functioning is achieved post treatment. This is also pertinent when considering motivation and engagement to undertake treatment, as many participants report improvements in broader functioning and wellbeing are equally or even more clinically meaningful to them than symptom reduction. These outcomes are related however, as symptom reduction is seen as a requirement to undertake work functions or with regard to improving their relationships (Benfer & Litz, 2023; Hinton, M et al., 2020; Kearney & Simpson 2015).  

Whilst there is limited research into the impact of PTSD treatment on these outcomes, initial evidence indicates that treatment for PTSD does lead to improvements in functional outcomes. These effects can be more modest than symptom reduction and tend to occur in the second half of treatment following symptom decline and are particularly salient where clients no longer meet diagnostic criteria for PTSD (Benfer & Litz 2023; Bonfils et al., 2022). 

It may also be useful to consider these factors when considering the timing and engagement of PTSD treatment. Where individuals have a high personal or family load, meeting basic needs may take precedence over accessing and participating in PTSD treatment. Additionally, recent studies provide some preliminary evidence to support the utility of assessing wellbeing. Fivecoat et al., (2023) report that those with social support may feel more able and confident to undertake treatment. Radstaak et al., (2022) indicated that individuals who reported higher levels of emotional, social and psychological wellbeing at baseline showed greater benefit from PTSD treatment.  

Recent Australian studies have also begun to incorporate functional outcome measures.  Both a South Australian doctoral randomised controlled trial providing CPT for PTSD (Elizabeth, 2020) and a Victorian public mental health service implementing CPT for PTSD (Casey et al., 2022) utilised the ORS (Outcome Rating Scale) (Miller & Duncan 2000) & SRS (Session Rating Scale) (Johnson et al., 2000) to consider patient experience of PTSD treatment and functional outcomes. The ORS is a commonly used measure of a client’s adjustment that includes a continuum on the domains of an individual’s personal, relationship, social and overall wellbeing with higher scores indicating better adjustment. In keeping with other preliminary research reporting functional outcomes, both these studies observed significant increases in ORS scores relative to pre-treatment following CPT.

When participating in CPT, many clients and clinicians report the significance of the initial and final Impact Statement as a core and enriching part of the treatment process. The impact statement is a 1-2 page written piece completed as a homework assignment by the client after Session 1 and again prior to Session 12. It talks about the impact the trauma has had on the individual’s life in terms of their sense of self, others and the world considering the key themes of safety, trust, power and control, esteem and intimacy.  

It is noteworthy to consider that final impact statement commonly encapsulates the meaning the client attaches to the changes achieved throughout treatment. Much of the time this is related to changes in how they see themselves, relationships with others and their sense of safety in the world together with their improved ability to relate and function within it. This is a moving and private written statement but could perhaps inform consideration of how to capture these functional and wellbeing outcomes objectively as a part of treatment evaluation.  

References 

Benfer, N., Litz, B.T. (2023). Assessing and addressing functioning and quality of life in PTSD. Current Treatment Options in Psychiatry 10, 1–20. doi:10.1007/s40501-023-00284-8 

Bonfils, K. A., Tennity, C. L., Congedo, B. A., Dolowich, B. A., Hammer, L. A., Haas, G. L. (2022). Functional outcomes from psychotherapy for people with posttraumatic stress disorder: A meta-analysis. Journal of Anxiety Disorders, 89, 102576. doi:10.1016/j.janxdis.2022.102576 

Casey.M., Yates.K., Tulchinsky.M., Zheng,A., Perera,D., Miller,M. & Nixon, R.D.V. (2022) Posttraumtic stress isorder and service utilisation outcomes following delivery of Cognitive Processing Therapy in a community mental health setting.  Clinical Psychologist, DOI: 10.1080/13284207.2022.2128642 

Elizabeth, M. (2020) The Effectiveness of combining Cognitive Processing Therapy with a Case Formulation Approach in the Treatment of Posttraumatic Stress Disorder – A Randomised Controlled Trial.  A thesis submitted to Flinders Univerwith in partial fulfilment of the requirements for the degree of Doctor of Philosophy (Clinical Psychology), College of Education, Psychology and Social Work.

Fivecoat, H. C., Lookatch, S. J., Mavandadi, S., McKay, J. R., & Sayers, S. L. (2023). Social factors predict treatment engagement in veterans with PTSD or SUD. The Journal of Behavioral Health Services & Research, 50(3), 286–300. doi:10.1007/s11414-022-09823-2 

Gallagher, M. W., Phillips, C. A., D’Souza, J., Richardson, A., Long, L. J., Boswell, J. F., Farchione, T. J., & Barlow, D. H. (2020). Trajectories of change in well-being during cognitive behavioral therapies for anxiety disorders: Quantifying the impact and covariation with improvements in anxiety. Psychotherapy, 57(3), 379–390. doi:10.1037/pst0000283 

Hinton,M., O’Donnell, M., Cowlishaw, S., Kartal, Z., Metcalf, O., Varker,T., McFarlane, A.C., Hopwood, M., Bryant, M.A., Forbes,D., Howard,A., Lau,W., Cooper, J & Phelps, A.J. (2020) Defining PTSD recovery: Benchmarking symptom change against wellbeing indicators (2021) Stress & Health, 37(3), 547-556.

Kearney, D. J., Simpson, T. L. (2015). Broadening the approach to posttraumatic stress disorder and the consequences of trauma. JAMA, 314(5), 453–455. doi:10.1001/jama.2015.7522

Radstaak, M., Hüning, L., Lamers, S., Bohlmeijer, E. T. (2022). Examining well-being in posttraumatic stress disorder treatment: An explorative study. Journal of Traumatic Stress, 35(3), 914–925. doi:10.1002/jts.22798 

Vogt, D., Kumar,S.A., Lee,L.O (2023) Examining Functioning and Wellbeing Outcomes in PTSD Treatment Outcome Research. PTSD Research Quarterly; 34(3)