In the treatment choice and preference studies reviewed above, exposure treatment was consistently one of the most frequently chosen treatments for PTSD (Angelo et al., 2008
; Becker et al., 2007
; Feeny et al., 2008
; Tarrier et al., 2006
; Zoellner et al., 2003
). Though this preference for exposure therapy may reflect a general preference for psychotherapy over pharmacotherapy (Barlow, 2004
; Becker et al., 2007
), research on the choice of exposure therapy for PTSD suggests a more complex picture. The evidence reviewed above suggests that perhaps the most critical determining factor for treatment choice is individual’s beliefs about treatment
. Indeed, individuals may have a complicated range of beliefs about the match between exposure treatment and PTSD (Cochran et al., 2008), including beliefs about the importance of talking about events, including the etiology and external nature of PTSD, beliefs about the effectiveness of treatment, and their perceived need for treatment.
Though the current treatment preference literature is weak in certain areas (e.g., demographic factors), it highlights a number of factors that potentially play an important role in treatment preference for exposure. In order to provide a conceptual framework for further research into preference for exposure therapy, we have proposed a belief-based model that incorporates what we believe to be potentially key empirically-supported factors that may influence exposure treatment preference. presents this belief-based model. This model includes the relationship between the factors discussed above and the hypothesized roles that they play in the prediction of treatment preference, highlighting both proposed direct and indirect effects. In interpreting this figure, the relative size of the ovals denoting key constructs and thickness of the lines denoting key associations are potentially indicative of stronger more consistent associations.
A Beliefs-based Model for Preference for Exposure Therapy for Chronic PTSD.
Notably, this model is broken into pre-trauma, event-related, and post-trauma factors. Prior to trauma exposure, it is likely that individuals have thought about what it would be like to have experienced a traumatic event (e.g., rape, combat, etc.) and already have some beliefs in place about how to handle certain types of problems and, in particular, beliefs about the importance of talking about problems. We propose that various demographic factors, such as education, cultural identity, and gender may exert their influence on preference largely through a general belief about how psychological treatments work, that is, the believed key treatment mechanism. In addition, other demographic factors such as prior trauma history may also exert their influence through this belief, though at present this is unstudied. Further, prior experience with either psychotherapy or pharmacotherapy for psychological problems may also exert its influence on treatment preference through pre-existing beliefs about treatment mechanism.
We have included two specific event-related factors, neither of which has proposed direct effects on preference for exposure. Obviously, the severity of a traumatic event is consistently associated with severity of post-trauma reactions and thus is included specifically in that regard (Brewin, Andrews, & Valentine, 2000
; Ozer, Best, Lipsey & West, 2003
). We have also included a variable we term “event stigma”, referring to the individual’s perception of societal or self stigma of the event. This is a factor has not been previously explored. However, we deem it potentially important for whether or not individuals will perceive a need for treatment. Indeed, given the focus of previous studies on more homogeneous samples, it may be that certain types of events or event characteristics are perceived as more stigmatizing than others (e.g., Frazier & Berman, 2008
; Hoge et al. 2004
; Ullman, 1996
); and, accordingly, individuals will be less likely to perceive a need or have a willingness to seek treatment.
Finally, we have included a variety of post-event factors. Of primary note, key factors here are beliefs about the effectiveness of therapy and one’s perceived need for treatment. Given that providers have pre-existing beliefs about the effectiveness of exposure for their particular clients (e.g., Becker, Zayfert & Anderson, 2004
), we have included this as a factor associated with whether or not an individual will perceive exposure therapy as an effective treatment. Further, event stigma, current symptom severity, and beliefs about the effectiveness of treatment are hypothesized to impact a belief about the need for treatment. We also have included a direct link between severity and choice of exposure, as individuals with higher symptom severity may be less likely to choose exposure therapy (Zoellner et al., 2008). Notably, as discussed above, fear of exposure itself does not appear to deter people from preferring exposure in general; and accordingly, it is not included as a central construct in this beliefs model.
Many areas of the proposed model have yet to be thoroughly investigated, but the model incorporates and synthesizes key factors found to date to play a role in treatment preference for exposure and provides an initial framework for their interaction. Obviously, our current knowledge of preference for exposure needs to be expanded to include much larger samples and various groups of trauma survivors with PTSD; and accordingly, this model should only be viewed as preliminary. Of particular note in this model is a shift away from focusing on demographic factors in predicting treatment preference to more specifically understanding individual’s belief systems about treatment seeking both in general and more specifically about exposure for the treatment of chronic PTSD. Ultimately, we believe that what individual’s believe about themselves and treatment will most dramatically influence their preference for or against a treatment. This may also have a profound influence on treatment adherence, dropout, and clinical outcome, reflecting either a good or poor aptitude by treatment match.