Management of Post-Traumatic Nightmares: a Review of Pharmacologic and Nonpharmacologic Treatments Since 2013.

PURPOSE OF REVIEW: Post-traumatic nightmares (PTN) are a common and enduring problem for individuals with post-traumatic stress disorder (PTSD) and other clinical presentations. PTN cause significant distress, are associated with large costs, and are an independent risk factor for suicide. Pharmacological and non-pharmacological treatment options for PTN exist. A previous review in this journal demonstrated that Prazosin, an alpha blocker, was a preferred pharmacological treatment for PTN and imagery rescripting therapy (IRT) was a preferred non-pharmacological treatment. Since that time, new and important research findings create the need for an updated review. RECENT FINDINGS: Based on the results of a recent study in the New England Journal of Medicine, Prazosin has been downgraded by both the American Academy of Sleep Medicine (AASM) and the Veterans Health Administration/Department of Defense (VA/DoD) for PTN. In Canada, Nabilone, a synthetic cannabinoid, appears to be promising. Few recent studies have been published on non-pharmacological interventions for PTN; however, recent data is available with regard to using IRT on an inpatient setting, with German combat veterans, and through the use of virtual technology. Recent evidence supports the use of exposure, relaxation, and rescripting therapy (ERRT) with children and individuals with comorbid bipolar disorder and PTN. Prazosin is no longer considered a first-line pharmacological intervention for PTN by AASM and VA/DoD. However, in the absence of a suitable alternative, it will likely remain the preferred option of prescribers. IRT and ERRT remain preferred non-pharmacological treatments of PTN. Combining cognitive behavior therapy for insomnia (CBT-I) with IRT or ERRT may lead to improved outcomes.

Attempting to reconcile large differences in Improving Access to Psychological Therapies recovery rates.

The Improving Access to Psychological Therapies initiative has a reported 50 percent recovery rate. Recently, Scott published a scathing report asserting that 9.2 percent is the correct rate. This alarming assertion requires a closer look and further scrutiny of the Improving Access to Psychological Therapies. Scott's study is fundamentally flawed in many ways; chiefly, the small ( n = 87), forensically involved, convenience sample is not representative of the Improving Access to Psychological Therapies population. Scott's study is more a limited-scope non-representative-sampled audit (or pilot study audit) of the Improving Access to Psychological Therapies. Given the large amount of public funds involved in the project, further research and a high degree of transparency is warranted.

Clinical Case Consultation and Experiential Learning in Cognitive Behavioral Therapy Implementation: Brief Qualitative Investigation.

There has been an increased emphasis on the implementation of cognitive behavioral therapy (CBT) to community mental health (CMH) systems due to its broad efficacy. Previous research has highlighted the importance of ongoing consultation in this process. The current study clarifies the role and process of clinical case consultation in the implementation of CBT to CMH from the consultants' perspective. Trainers from two large-scale implementation initiatives (n = 27) were surveyed regarding their strategies used in the consultation process. Historically, researchers have focused on trainees who view relational variables as the most effective elements of consultation; however, in the current study, trainers perceived experiential learning as being the most effective consultation strategy for helping CMH clinicians learn CBT. Other aspects of consultation such as case conceptualization and practice sample review are discussed in terms of their relative perceived utility in raising CMH clinician's competency to treat comorbid patients.

Implementation of transdiagnostic cognitive therapy in community behavioral health: The Beck Community Initiative.

OBJECTIVE: Progress bringing evidence-based practice (EBP) to community behavioral health (CBH) has been slow. This study investigated feasibility, acceptability, and fidelity outcomes of a program to implement transdiagnostic cognitive therapy (CT) across diverse CBH settings, in response to a policy shift toward EBP. METHOD: Clinicians (n = 348) from 30 CBH programs participated in workshops and 6 months of consultation. Clinician retention was examined to assess feasibility, and clinician feedback and attitudes were evaluated to assess implementation acceptability. Experts rated clinicians' work samples at baseline, mid-, and end-of-consultation with the Cognitive Therapy Rating Scale (CTRS) to assess fidelity. RESULTS: Feasibility was demonstrated through high program retention (i.e., only 4.9% of clinicians withdrew). Turnover of clinicians who participated was low (13.5%) compared to typical CBH turnover rates, even during the high-demand training period. Clinicians reported high acceptability of EBP and CT, and self-reported comfort using CT improved significantly over time. Most clinicians (79.6%) reached established benchmarks of CT competency by the final assessment point. Mixed-effects hierarchical linear models indicated that CTRS scores increased significantly from baseline to the competency assessment (p < .001), on average by 18.65 points. Outcomes did not vary significantly between settings (i.e., outpatient vs. other). CONCLUSIONS: Even clinicians motivated by policy-change rather than self-nomination may feasibly be trained to deliver a case-conceptualization driven EBP with high levels of competency and acceptability. (PsycINFO Database Record

Model-Consistent Cognitive Behavioral Therapy Supervision: A Case Study of a Psychotherapy-Based Approach.

There is a great need for training in cognitive behavioral therapy (CBT) for community clinicians who work in public mental health systems where resources are low and demands are high. Researchers have found that simply attending intensive CBT workshops will not result in adherent or competent CBT being delivered, rather ongoing CBT supervision/consultation has been found to be associated with the best training outcomes. Psychotherapy-based approaches to supervision have recently received some attention for their value in providing experiential learning. What follows is a case example of a community clinician who had little previous training in CBT and following an intensive training and 16 weeks of CBT supervision had substantial gains in her CBT adherence and competency ratings. Recommendations such as the value of experiential learning are discussed.