Regardless of intervention type, over time, after an assault, women’s views of themselves, others, and the world in general became more positive. This “healthy” shift in beliefs is consistent with patterns of natural recovery seen among assault survivors, where psychological reactions such as PTSD symptoms and depression improve overtime for the majority of women with no intervention.
More specifically, however, the brief cognitive behavioral intervention, but not supportive counseling, was associated with a long-term improvement in one’s sense of self and safety. Moreover, for the brief cognitive intervention, but not the assessment or supportive counseling interventions, changes in perception of one’s self and safety mediated longer-term changes in trauma-related symptoms.
Specifically, there was evidence that the effects of the brief CBT intervention produced changes in perceptions of oneself and one’s safety and further that these changes mediated pre to follow-up changes in PTSD (at trend level for safety), depression, and anxiety symptoms. Although there was some evidence that both brief CBT and assessment produced improvement in these beliefs, there was no evidence of these changes having mediational effects for those receiving the assessment intervention. This suggests that the brief CBT affects perceptions of oneself and one’s safety, which in turn reduces long-term symptoms. One obvious interpretation is that the inclusion of cognitive restructuring in the brief CBT, but not in the assessment intervention, directly reduced the negative beliefs and affected symptoms. Alternatively, the in vivo
homework assignments in the brief CBT, that is, having individuals directly approach non-dangerous trauma-reminders, may have had a dual effect in that it reduced negative beliefs about one’s safety; similarly both successful completion of imaginal and in vivo exposure disconfirm one’s belief that they will not be able to cope with confronting trauma reminders and will “fall apart”, thus increasing sense of one’s self efficacy. Indeed, in the treatment of chronic PTSD, the combination of imaginal and in vivo
exposure with cognitive restructuring has been shown to produce optimal outcomes over the individual components alone,
though patients in imaginal exposure were not allowed any discussion (i.e., processing) of their imgainal exposure experiences. Others have failed to find an additive benefit of cognitive restructuring over combined imaginal and in vivo
Indeed, Foa and Rauch
suggest that disconfirmation of negative beliefs about safety and self occurring during imaginal and in vivo exposure may be responsible for changes in these negative cognitions because treatment that included imaginal and in vivo
exposure plus cognitive restructuring did not produce greater change in negative cognitions than imaginal and in vivo
exposure alone. Similar arguments have been made more broadly by Hofmann.
Extending this to the prevention of chronic PTSD, it is unclear what are critical CBT intervention elements facilitating cognitive change at the present time. Another possible explanation is that the brief CBT was the only intervention where there was a direct expectation for belief change given to the client (i.e., cognitive restructuring); and therefore, there was an expectation that beliefs would change, and participants reported such shifts.
Key shifts in beliefs centered on views about one’s self and one’s safety. Specifically, positive shifts in these beliefs during the brief-CBT intervention mediated longer-term improvement in trauma-related symptoms. The importance of shifts in negative beliefs about one’s self have long been highlighted in the development of chronic PTSD.[3,15,18,48-50]
For example, in a non-intervention, prospective study, the appraisal that the trauma had permanently changed oneself in a negative way, negative appraisals of one’s emotions, and mental defeat during the trauma predicted later PTSD severity over and above initial symptoms.
Yet, the present study is the first to extend this work to a prevention arena showing intervention-related mediational effects. Notably, negative beliefs about oneself are also central to depression,
and given the overlap between PTSD and depression,
these improvements in brief CBT may be particularly important to longer-term outcome. Shifts in perceptions of one’s safety also emerged as a potentially important brief CBT intervention-related mediator of post-assault adjustment. Similar to the importance of self, fear of threat to one’s safety or, one’s sense of ongoing threat, has been highlighted in cross-sectional and prospective studies.[49,53,54]
In association with trauma-related avoidance, it may be that, as Ehlers and colleagues
suggest, intrusive memories, through temporal association with the trauma, serve as warning signals indicating impending danger. This sense of serious current threat to one’s safety may be a fundamental part of a chain of cause and effect that forms a circuit or loop, that is, a key component of a negative feedback loop, surrounding the persistence of trauma-related intrusions and avoidance.
Finally, it is worth noting, for individuals in the supportive counseling intervention, beliefs about oneself (PBRS) and one’s safety in the world (PBRS) failed to show reliable change over time. Thus, the present study also extends the findings of early intervention studies by Bryant and colleagues[22,23,55]
suggesting supportive that counseling yields little or no symptom reduction to also suggest limited reduction in negative beliefs following supportive counseling.
Several additional limitations merit discussion. Given the desire to include an active control intervention and to compare the larger trial
to other similar intervention trials[22,23]
, a wait-list control was not included and thus did not allow for the examination of natural recovery. Further, these beliefs may be specific to reactions following assault, as our sample was limited to female assault survivors, and may not be as relevant for other traumatic events. Finally, the present design does not allow for full examination of the causal role of negative beliefs in impairing recovery; it may be that, while intervention-related changes in some of these beliefs temporally mediate long-term symptoms, they may still reflect correlates rather than causes of recovery. Further, establishing temporal precedence in clinical trials is difficult for variables that simultaneously shift over the course of intervention, which makes interpretation of mediation difficult at best. However, we have employed state-of-the-art methods suggested by Hofmann
to establish temporal precedence and Kraemer and colleagues
to best examine potential mediation. Regardless, the present study clearly shows “healthy” cognitive shifts in beliefs about oneself, others, and the world that coincide with recovery following assault. In addition, our findings highlight the importance of further examination of beliefs particularly related to one’s sense of self and safety. Such work may lead to both a better understanding of natural recovery and more specific cognitive theories of acute and chronic PTSD.