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Danish study of comparing two treatments for sexual abuse


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Danish study comparing systemic and analytic treatments for sexual abuse. Initially, systemic proved more effective, however, gains were not maintained at follow up leaving the two treatments …

Danish study comparing systemic and analytic treatments for sexual abuse. Initially, systemic proved more effective, however, gains were not maintained at follow up leaving the two treatments equivalent in effect.

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  • 1. Psychology and Psychotherapy: Theory, Research and Practice (2014), 87, 191–208 © 2013 The British Psychological Society Analytic versus systemic group therapy for women with a history of child sexual abuse: 1-Year follow-up of a randomized controlled trial Henriette Elkjaer1,2 *, Ellids Kristensen3,4 , Erik L. Mortensen5 , Stig Poulsen2 and Marianne Lau1 1 Stolpegaard Psychotherapy Centre, Mental Health Services, Capital Region of Denmark, Gentofte, Denmark 2 Department of Psychology, University of Copenhagen, Denmark 3 Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark 4 Sexological Clinic, Psychiatric Centre Copenhagen, Mental Health Services, Capital Region of Denmark, Gentofte, Denmark 5 Institute of Public Health and Center for Healthy Aging, University of Copenhagen, Denmark Objective. This randomized prospective study examines durability of improvement in general symptomatology, psychosocial functioning and interpersonal problems, and compares the long-term efficacy of analytic and systemic group psychotherapy in women 1 year after completion of treatment for childhood sexual abuse. Design and Methods. Women (n = 106) randomly assigned to analytic or systemic psychotherapy completed the Symptom Checklist-90-R, Global Assessment of Func- tioning, Global Life Quality, Registration Chart Questionnaire, and Flashback Registration at pre-treatment, post-treatment, and at a 1-year follow-up. Results. Post-treatment gains were significant for both treatment modalities on all measures, but significantly larger after systemic therapy. Significant treatment response was maintained 1-year post-treatment, but different trajectories were observed: 1 year after treatment completion, improvements for analytic therapy were maintained, whereas they decreased after systemic therapy, resulting in no statistically significant difference in gains between the groups at the 1-year follow-up. Despite maintaining significant gains, more than half of the patients remained above cut-off for caseness concerning general symptomatology at post-treatment and at 1-year follow-up. Conclusion. The findings stress the importance of long-term follow-up data in effect studies. Different trajectories were associated with the two treatments, but improve- ment in the two treatment groups did not differ significantly at the 1-year follow-up. Implications of the difference in trajectories for treatment planning are discussed. *Correspondence should be addressed to Henriette Elkjaer, Stolpegaard Psychotherapy Centre, Mental Health Services, Stolpegaardsvej 20, 2820 Gentofte, Denmark (email: DOI:10.1111/papt.12011 191
  • 2. Practitioner points Both analytic and systemic group therapy proved efficient in improving general symptomatology, psychosocial functioning, and interpersonal problems in women with a history of CSA and gains were maintained at a 1-year follow-up. Despite maintaining statistically significant gains at the 1-year follow-up, 54% of the patients remained above the cut-off for caseness with respect to general symptomatology, which may indicate a need for further treatment. Different pre-post follow-up treatment trajectories were observed between the two treatment modalities. Thus, while systemic group therapy showed a significantly better outcome immediately after termination, gains in the systemic treatment group decreased during follow-up, while gains were maintained during follow-up in analytic group therapy. Childhood sexual abuse (CSA) is recognized as a major risk factor for developing long-term psychiatric and social problems (Briere Elliott, 2003; Jonas et al., 2011; Paolucci, Genuis, Violato, 2001; Sachs-Ericsson, Blazer, Plant, Arnow, 2005; Spataro, Mullen, Burgess, Wells, Moss, 2004). Adults with a history of CSA are likely to experience higher levels of anxiety, depression (Peleikis, Mykletun, Dahl, 2005), eating disorders (Carter, Bewell, Blackmore, Woodside, 2006; Sanci et al., 2008), post-traumatic stress disorder (PTSD) (Peleikis et al., 2005; Raghavan Kingston, 2006; Widom, 1999), psychosis (Read, van Os, Morrisson, Ross, 2005), sexual dysfunction (Buehler, 2008; Kristensen Lau, 2011; Najman, Dunne, Purdie, Boyle, Coxeter, 2005; Rellini, 2008), disadvantaged socio-economical status (Currie Widom, 2010; Kristensen Lau, 2007; Wijma, Samelius, Wingren, Wijma, 2007), suicidal behaviour (Akyuz, Sar, Kugu, Dogan, 2005; Bebbington et al., 2009; Roy Janal, 2006; Ullman Najdowski, 2009), and revictim- ization (Arata, 2002; Classen, Palesh, Aggarwal, 2005; Desai, Arias, Thompson, Basile, 2002; Kimerling, Alvarez, Pavao, Kaminski, Baumrind, 2007; Lau Kristensen, 2010). Furthermore, children of women who were sexually abused during childhood are at heightened risk for physical and sexual abuse (Avery, Hutchinson, Whitaker, 2002; Collishaw, Dunn, O’Connor, Golding, 2007; DiLillo, Tremblay, Peterson, 2000). Because CSA is associated with long-lasting and significant sequelae, it is critical to identify treatments that reduce these difficulties and promote lasting symptomatic remission. Group psychotherapy is generally regarded as the treatment of choice for sexual abuse (Alexander, Neimeyer, Follette, Moore, Harter, 1989; Richter, Snider, Gorey, 1997). The opportunity to explore their experience with peers allows group members to break through the secrecy surrounding sexual abuse, stimulates a feeling of belonging, and alleviates the sense of feeling alone. Evidence suggests that group psychotherapy is effective in treating women with a history of CSA, and studies show maintenance or improvement in outcome during follow-up periods with regard to psychological distress, psychosocial functioning, and symptoms of PTSD (Peleikis Dahl, 2005; Taylor Harvey, 2010). However, long-term follow-up studies of treatment outcome in this population are relatively sparse, and more knowledge is needed regarding which type of group psychotherapy that is most efficient and has the most durable effect. To our knowledge, only one outcome study exists (Kriedler, Einsporn, Zupancic, Masterson, 1999) within the framework of the family systems model of treatment for women with sequelae of CSA, and the efficacy of analytic versus systemic group psychotherapy has not been investigated before. Within an analytic framework, long-term follow-up of treatment outcome for this population has been conducted, reporting either 192 Henriette Elkjaer et al.
  • 3. maintenance or increase of gains post-treatment (Alexander et al., 1989; Richter et al., 1997). A meta-analysis on the efficacy of systemic therapy reported stable follow-up results on other patient populations (Von Sydow, Beher, Schweitzer, Retzlaff, 2010), but no follow-up studies within a systemic framework exist for this population. In a randomized trial conducted by Lau Kristensen (Lau Kristensen, 2007; Munk-Jørgensen, 2008), outcomes of analytic and systemic group psychotherapy were compared for women with a history of intra-familial CSA. Analysis of pre- to post-treatment outcome indicated that both therapies led to significantly fewer general symptoms, improvement in quality of life, and better psychosocial functioning. However, the outcome for patients who received systemic group psychotherapy was significantly better. Aims of the study The aim of this study was to ascertain the durability of gains achieved 1 year after treatment completion by the women in the previously described sample (Lau Kristensen, 2007), and to determine whether the difference in the initial gains persisted. As existent follow-up studies consistently report maintenance or occasionally increase of post-treatment gains, we expected our groups to maintain gains. The following hypotheses were tested: (1) Improvements in measures of general symptomatology, global quality of life, overall psycho-social functioning, and flash backs were maintained in both groups after 1 year, and (2) the difference in improvements between analytic and systemic group psychotherapy in favour of systemic group psychotherapy was maintained at the 1-year follow-up. Materials and methods Participants Participants were Danish speaking women 18 years of age or older, referred during the 3-year study period for specialized outpatient group therapy for long-term problems related to CSA. The major criterion for inclusion in this study was clear memory of at least one incident of hands-on intra-familial CSA before the age of 16 committed by a biological relative or non-biological family member, and prolonged psychiatric symptoms related to the history of CSA, defined as follows: (1) Sexual abuse with physical contact but without penetration (kissing, touching, fondling of genitals) or (2) sexual abuse with vaginal, oral, and/or anal penetration. Exclusion criteria for the study were as follows: (1) pregnancy, (2) presence of active suicidality, (3) symptoms of psychosis, (4) mental or organic impairment, (5) current alcohol or drug abuse, and (6) not understanding Danish. Design and procedures Patients with long-term sequelae from CSA referred to Stolpegaard Psychotherapeutic Centre, Denmark, during the period of intake, September 1998 to February 2001, were included in the randomized controlled clinical trial with pre-post follow-up test design if they fulfilled the inclusion criteria. This randomized trial was nested within a Danish prospective multi-centre study (Kristensen Lau, 2007). Stolpegaard Psychotherapeutic Centre is part of the Danish Mental Health Services and treats around 1,250 patients with non-psychotic disorders each year. At the time of the study, two treatment modalities co-existed at the centre for the treatment of adults with 1-Year follow-up of a randomized trial 193
  • 4. long-term sequelae from CSA, analytic and systemic group psychotherapy. No formal knowledge existed whether one was better than the other. Treatment took place in a naturalistic setting, meaning that recruitment, selection, patient-characteristics, and treatment were routine practice. Treatment was provided free of charge by the public Danish health care system. Patients were referred by their general practitioner or a specialist in psychiatry. Upon initial referral, assessors not involved in the treatment conducted an assessment for eligibility at the centre. Descriptive data were collected using a clinical interview and a self-administered questionnaire. Random allocation to treatment of patients admitted to the trial was achieved by setting up clusters of thirty patients and using a lottery to allocate patients to one of the two treatment groups. Mean waiting time from assessment until start of treatment was 158 days (Æ79 days). To evaluate treatment outcome, assessments were conducted pre-treatment, post-treatment, and at a 1-year follow-up. At the 1-year follow-up, questionnaires were mailed with a stamped and addressed return envelope. If a questionnaire was not returned within 2 weeks, a new questionnaire and a reminder letter were mailed to the participant. This procedure was repeated as needed to obtain as complete 1-year data as possible. The immediate outcome of the randomized trial has been reported in a previous article (Lau Kristensen, 2007). This article presents 1-year follow-up data from the randomized trial. Measures Psychiatric interview At intake, a semi-structured clinical interview was conducted providing the following data. Socio-demographics: age, marital status, children living at home, education, and occupation. Psychiatric data: psychiatric history, attempted suicide and current suicide ideation, current or earlier substance use and abuse, psychotic symptoms, organic psychic impairment, psychopharmacological treatment, and present ICD-10 diagnosis. History of childhood: description of child sexual and physical abuse. The following patient self-completed questionnaires were used in a Danish translation at start, after treatment, and at 1-year follow-up. Primary outcome measure The Symptom Checklist-90-R (SCL-90-R) (Derogatis, 1994) is a 90-item self-report inventory assessing general psychiatric symptomatology on nine primary symptom dimensions. Research suggests that the SCL-90-R is a reliable and valid inventory (Derogatis, 1994; Derogatis, Rickels, Rock, 1976). The SCL-90-R Global Severity Index (GSI) is the mean of all item scores and provides a measure of the current overall level of psychological distress. High scores on the GSI indicate high levels of psychological distress (Hill Lambert, 2004). Cronbach’s alpha for GSI of the Danish version of SCL-90-R is 0.97 (Olsen, Mortensen, Bech, 2007). For the present clinical sample, Cronbach’s alpha for GSI was 0.97. The cut-off for caseness on GSI was set to 1.08 in accordance with Olsen et al. (Olsen, Mortensen, Bech, 2006). Secondary outcome measures The following instruments were added to shed more light on psychosocial functioning, quality of life, interpersonal relationships, and flash backs. 194 Henriette Elkjaer et al.
  • 5. The Global Assessment of Functioning (GAF) (American Psychiatric Association, 2000a), Axis V of the DSM-IV, is a widely used single-item measure of overall psychosocial functioning during the preceding month. The score range is 1–100 with 100 indicating optimal functioning. Research has demonstrated GAF to be a reliable and valid measure (American Psychiatric Association, 2000b). In this study, a self-report form with separate scoresonsocial and mental functioning wasused (Bodlund,Kullgren, Ekselius,Lindstrom, von Knorring, 1994). The lower of the two scores was used to assess psychosocial functioning. Thepatient self-report version of the GAF scale has been reported to correlate 0.62 with experts’ ratings (Bodlund et al., 1994; Ramirez, Ekselius, Ramklint, 2008). Global Life Quality (GLQ) (Husby, Dahl, Heilberg, Olafsen, Weisaeth, 1985; Valbak, 2001) is a single-item global measure of the patient’s self-reported current perception of quality of life. GLQ is rated on a 0–6 point Likert scale. Registration Chart Questionnaire (RCQ) is a 10-item self-report form. Items are rated on a 0–6 point Likert scale and scored in two subscales: RCQ-general and RCQ-relation. The questionnaire is a modified version of earlier reliability-tested scales (Husby et al., 1985; Valbak, 2001). In the present clinical sample, Cronbach’s alpha for RCQ was 0.78. Cronbach’s alpha for the two subscales, RCQ-general and RCQ-relational, was 0.79 and 0.63, respectively. RCQ-general: Five items highlights general functioning: bothered by problems/symptoms, perceived social functioning (occupational/study ability), per- ceived problem-solving capacity, perceived ability to accept the feelings and attitudes of others, and perceived ability to tolerate and express own emotions. RCQ-relation: Five items highlights interpersonal relationships, relationship to mother, father, siblings, persons of the same sex, and persons of the opposite sex. Flashback Registration is a categorical two-item self-report questionnaire designed for this study measuring recurrent and intrusive disturbing recollections of the CSA in sexual and non-sexual situations. Each item is scored on a 6-point scale ranging from every day to never. The highest value of the two items was used to assess presence of flashbacks. Descriptive follow-up data: Self-reported details on additional psychological and psychiatric treatment were used at the 1-year follow-up only. Treatments Analytic and systemic group psychotherapy was offered as treatment in this randomized controlled trial for adult women suffering from long-term problems related to CSA. Both therapygroupswereleadbytwoexperiencedtherapistswithseveralyears oftraininginthe specific treatment model. To ensure that the therapeutic model was followed, a certified supervisor monitored the therapists regularly. Both treatment groups were slow-open outpatient groups where new patients could begin the allocated treatment whenever a patient in the allocated group had completed the treatment. Thus, there were a constant number of patients in each group although they were in different phases of treatment. Analytic group therapy (Group A) was based on the theory of group analysis (Foulkes, 1986). To reduce anxiety and promote a safe and mutually disclosing relationship for this particular group of patients, a version of analytic group therapy, which provided more structure and support than recommended in the original approach, was offered (Alexander et al., 1989). The Group A intervention focused on intra-psychic and interpersonal dynamics and difficulties both in past and present relationships and within the group. According to Nemiroff et al., interpersonal psychoanalysis is particularly suited to facilitate change in women who were sexually abused as children because both the abuse andthetherapyarefundamentallyrelational(Nemiroff,Schindler,Schreiber2000). 1-Year follow-up of a randomized trial 195
  • 6. Group A had eight consecutive patients who met once a week (2.25 hr/week) for 12 months (46.3 Æ 15.3 weeks and 104.2 Æ 34.5 hr). Systemic group therapy (Group S) was based on systemic theory (Holme, 1999) and was solution focused. Group S focused on individual processes and employed a highly structured framework with initial goal setting and rounds during sessions. At each session, it was decided who had speaking time, when and for how long, and participants were supported by an active therapist role. The main task was to reframe the patients’ life histories and make them construct more rewarding perceptions of themselves and their situations, thus creating new behavioural possibilities. Every second week there was 1 hr of psycho-education with the group choosing the topics. The Group S intervention focused on the treatment of flashbacks, guilt, and validation of perceptions and feelings. Group S had six consecutive patients who met twice a week (5.0 hr/week) for 5 months (17.1 Æ 5.4 weeks and 85.4 Æ 27.1 hr). Statistical analysis Statistical analysis was performed using IBM SPSS statistics 18.0 software (IBM Corporation, To examine comparative treatment effects of the two different treatments, both intention to treat (ITT) and completer analyses (CA) were carried out. ITT analysis is presented here, unless otherwise noted. Analysis of variance (ANOVA) with Greenhouse-Geisser adjustment was performed with the treatment group as a between factor and the three time-points as repeated measures. Due to a significant group difference in baseline scores on GSI, an additional Repeated Measures ANCOVA was performed for GSI adjusted for baseline score. To account for missing data, a conservative Last Observation Carried Forward (LOCF) method was used. Stuart’s test was used to examine change in the occurrence of flashbacks over time (Marascuilo McSweeney, 1977). The level of significance was set at two-tailed p .05. Effect sizes (pre-therapy to 1-year follow-up) were calculated for GSI, GAF, GLQ, and RCQ, using the formula: ES = (Mean1 À Mean2)/s, where s = pooled standard deviation √([SD12 + SD22 ]/2).Effectsizeswereinterpretedasfollows:ES 20:noeffect,ES = 0.20– 0.50: small effect, ES = 0.50–0.80: medium effect, ES 0.80: large effect (Cohen, 1988). For GSI, change was considered statistically significant if the Reliable Change Index (RCI) was exceeded: Score1 À Score2 RCI, with RCI = 2 9 √2 9 SD1 9 √(1 À Cron- bach’s a) (Schauenburg Strack, 1999). To calculate the cut-off (c) for clinically significant change, the formula from Jacobsen et al. (Jacobson Truax, 1991) was used: c = (SD0 9 Mean1 + SD1 9 Mean0)/(SD0 + SD1), with Mean0 and SD0 from the Danish norm for women (Olsen et al., 2006), and Mean1 and SD1 from the clinical population. Ethics The study was approved by the Committees on Biomedical Research Ethics of the Capital Region of Denmark. All participants gave written consent for participation after receiving a complete written and oral description of the study. Results Patient attrition and characteristics One hundred and six women began allocated treatment, 86 women (81%) completed treatment, and 1-year follow-up data were available for 68 women (64%). Thus, 38 patients 196 Henriette Elkjaer et al.
  • 7. were drop-outs at follow-up and were treated according to the LOCF in the ITT-analysis. For detailed information, see the CONSORT model (Moher, Schulz, Altman, 2001) (Figure 1). No difference was found between the two groups with regard to waiting time before start of treatment (independent samples t-test: ns). No changes in GAF or GSI scores were found in either group during the waiting period (Lau Kristensen, 2007). Pre-therapy, the two treatment groups were comparable in terms of socio-demo- graphics and CSA (Table 1). Sixty-three per cent had previously received psychothera- peutic or psychiatric treatment (Group A: 65%; Group S: 61%), 22% as psychiatric inpatients (Group A: 21%; Group S: 22%). In both groups, 19% received antidepressant medication (v2 = 0.002, df = 1, p = .964). No difference in attendance to additional treatment during the 1-year follow-up period was found between the groups. Of the 68 follow-up patients, 21 patients (30.9%) had received at least five sessions’ of psychological/psychiatric outpatient treatment (Group A: 10 patients, Group S: 11) and four of those plus one additional patient had been hospitalized (Group A: 2 and Group S: 3). For the total sample of patients a statistically Allocated to intervention A (n = 77) Did not receive allocated intervention (n = 25): • Did not show up (n = 11) • No treatment wish (n = 5) • Unable to attend group psychotherapy (n = 4) • No longer met the inclusion criteria (n = 4) • Other reasons (n = 1) Started on intervention A (n = 52) (intention to treat) Allocated to intervention S (n = 74) Did not receive allocated intervention (n = 20) • Did not show up (n = 3) • No treatment wish (n = 4) • Unable to attend group psychotherapy (n = 5) • No longer met the inclusion criteria (n = 4) • Other reasons (n = 4) Started on intervention S (n = 54) (intention to treat) Randomized (n = 151) Early treatment drop-out (n = 3) Lost post-analysis (n = 9) Early treatment drop-out (n = 4) Lost post-analysis (n = 4) Pre and Post evaluated (n = 40) Pre and Post evaluated (n = 46) Emigrated (n = 2) Terminal physical illness (n = 1) Did not wish to participate anymore (n = 2) Lost at one-year analysis (n = 4) Emigrated (n = 2) Lost at one-year analysis (n = 7) Pre/Post/One-year evaluated (n = 31) (Completer analysis) Pre/Post/One-year evaluated (n = 37) (Completer analysis) Figure 1. Flow diagram: Subject progress CONSOORT diagram. 1-Year follow-up of a randomized trial 197
  • 8. significant relationship between prior in-/outpatient treatment and seeking further treatment during follow-up was detected (v² = 6.17, p = .013), but the association was only significant in Group S (Group A: v² = 1.015, p = .314; Group S: v² = 5.918, p = .015). Questionnaire scores Pre-therapy, mean SCL-90-R GSI scores were significantly higher in Group A (p = .028). However, the number above the cut-off for caseness (GSI score 1.08) was similar in the two groups. No pre-therapy differences were observed between the two groups on GAF, GLQ, RCQ-relational, or RCQ-general. Overall treatment response The pre-post treatment outcome is summarized in Table 2. The gains were significant for both treatment modalities on all measures, but significantly larger in Group S. The results are reported in details elsewhere (Lau Kristensen, 2007). Table 1. Socio-demographic, psychiatric, and childhood sexual abuse (CSA) data at pre-therapy, Group A (n = 52) versus Group S (n = 54) Group A Group S Significance (p) Age in years Æ SD 34.9 Æ 11.1 33.7 Æ 9.1 nsa Education: ≥10 years of schooling (%) 38 (73.1) 36 (66.7) nsb,c Vocational training nsb,c No formal education (%) 20 (38.5) 19 (35.2) Semi-skilled and skilled (%) 23 (44.2) 22 (40.8) Longer theoretical training/academic (%) 8 (15.4) 12 (22.2) Marital status: Cohabitant (%) 18 (34.6) 25 (46.3) nsb,c Primary psychiatric diagnosis: ICD-10 nsb F0–39: Affective disorders (%) 4 (7.7) 6 (11.1) F40–41: Anxiety disorders (%) 7 (13.5) 8 (14.8) F43: PTSD, adjustment disorders (%) 9 (17.3) 16 (29.6) F42 and F44–49: Other nervous diseases (%) 4 (7.7) 0 (0.0) F50–59: Behavioural syndromes (%) 2 (3.8) 1 (1.9) F60–62: Personality disorders (%) 26 (50.0) 23 (42.6) Age at CSA onset (years Æ SD) 5.7 Æ 2.9 6.1 Æ 3.3 nsa,d Duration of CSA (years Æ SD) 7.7 Æ 4.9 6.6 Æ 3.9 nsa,e Number of offenders (n Æ SD) 1.7 Æ 1.0 1.5 Æ 0.8 nsa CSA nsb With physical contact but without penetration, n (%) 17 (32.7) 19 (35.2) With oral, anal, or vaginal penetration, n (%) 35 (67.3) 35 (64.8) Note. Values are presented as n (%) unless otherwise indicated. PTSD = post-traumatic stress disorder; SD = standard deviation. a Mann–Whitney test. b v2 test. c Missing data on one patient from Group A and one from Group S. d Missing data on two patients from Group S. e Missing data on two patients from Group A and four from Group S. 198 Henriette Elkjaer et al.
  • 9. One year after treatment completion,ANOVA was performed using treatment group as a between factor and the three time-points as repeated measures. ITT analysis demonstrated that improvement (as measured with Greenhouse-Geisser adjustment) was statistically significant at 1 year on all measures (p .001). On two of five measures the Time 9 Treatment group interaction was significant (GSI, p = .029 and RCQ-general, p = .002), meaning that a difference in course was found over time for the two groups. On two more measures, even though not significant, there was a trend in the same direction (GAF, p = .077 and GLQ, p = .057). For visual comparison, the difference in courseon GSI across time-points for the two groups is shown in Figure 2. In addition, due to a significant group difference in baseline scores on GSI, Repeated Measures ANCOVA was performed for GSI adjusted for baseline score.The ANCOVA supported the Time 9 Treatment group interaction (p = .013) found in the ANOVA. During follow-up, Group A maintained gains on all measures, whereas Group S showed statistically significant worsening of scores on GSI, GLQ, RCQ-general, and RCQ-relation (Table 2). Consequently, 1 year after treatment completion, no statistically significant difference was found between the two groups in achieved gains from pre-treatment to follow-up on either measure (Table 3). Medium effect sizes were found for both groups, except on RCQ-relation where effect sizes were small (Table 2). CA showed essentially the same pattern as ITT (Table 3). At the 1-year follow-up, a decrease of flashbacks was statistically significant for both groups (Stuart’s test of equality: p .001). As shown in Table 4, the occurrence of flashbacks differed over time for the two groups: in Group S, the main change took place during therapy, whereas in Group A, change took mainly place during follow-up. Table 2. Treatment response on GSI, GAF, GLQ, and RCQ (intention to treat analyses), Group A (n = 52) versus Group S (n = 54) Measure Pre-therapy M Æ SD Post-therapy M Æ SD 1-Year follow-up M Æ SD Difference pre-post Difference post-1-year Effect size pre-1-year GSI Group A 1.89 Æ 0.73 1.57 Æ 0.73 1.50 Æ 0.84 À0.32*** À0.07 ns 0.50 Group S 1.60 Æ 0.61 0.97 Æ 0.68 1.15 Æ 0.79 À0.63*** 0.18* 0.64 GAF Group A 53.0 Æ 11.4 60.4 Æ 12.0 60.6 Æ 13.7 7.4** 0.1 ns 0.60 Group S 54.4 Æ 13.3 69.0 Æ 15.0 67.2 Æ 18.4 14.6*** À1.8 ns 0.80 GLQ Group A 2.80 Æ 1.00 3.61 Æ 1.48 3.72 Æ 1.52 0.81*** 0.10 ns 0.72 Group S 2.90 Æ 1.02 4.20 Æ 1.29 3.66 Æ 1.27 1.30*** À0.54** 0.66 RCQ-general Group A 2.83 Æ 0.75 3.28 Æ 1.03 3.38 Æ 1.01 0.45*** 0.10 ns 0.62 Group S 3.04 Æ 0.98 4.13 Æ 1.03 3.69 Æ 1.24 1.09*** À0.44** 0.58 RCQ-relation Group A 2.72 Æ 1.09 3.03 Æ 1.14 2.97 Æ 1.22 0.31** À0.06 ns 0.22 Group S 2.95 Æ 1.05 3.47 Æ 1.12 3.19 Æ 1.16 0.52*** À0.28** 0.22 Note. GSI = Global Severity Index from SCL-90-R; GAF = Global Assessment of Functioning; GLQ = Global Life Quality; RCQ = Registration Chart Questionnaire; M = mean; SD = standard deviation. Paired samples t-test: *p .05; **p .01; ***p .001. 1-Year follow-up of a randomized trial 199
  • 10. Pre-treatment, 84% of patients were above the cut-off for caseness on GSI (Group A: 46 patients, Group S: 43 patients; v²: ns). This proportion was reduced to 54% post-treatment (Group A: 38 patients, Group S: 19 patients; v²: p .001). Sixty patients (57%) were above the cut-off for caseness at the 1-year follow-up (Group A: 33 patients and Group S: 27 patients; v²: ns). In the present sample, a statistically significant improvement in the GSI corresponded to a change of at least RCI ≥ 0.41. Using the RCI as criterion, from pre-treatment to post-treatment four patients (4%) deteriorated (Group A: 3/52 vs. Group S: 1/54; OR 3.25, 95% confidence interval (CI) 0.33–32.25, p = .315), two of those both statistically and clinically (Group A: 1/52 vs. Group S: 1/54; OR 1.04, 95% CI 0.06–17.06, p = .979), 56 patients (53%) remained unchanged (Group A: 32/52 vs. Group S: 24/54; OR 2.00, 95% CI 0.92–4.34, p = .080), whereas 46 (43%) improved (Group A: 17/52 vs. Group S: 29/54; OR 0.42, 95% CI 0.19–0.92, p = .031), 29 of those both statistically and clinically (Group A 9/ Figure 2. Global Severity Index across the three time-points for Group A (n = 52) and Group S (n = 54) (intention to treat). Table 3. Changes in scores from pre-treatment to 1-year follow-up – GSI, GAF, GLQ, and RCQ Group A, ITT (n = 52) Group S, ITT (n = 54) pa Group A, CA (n = 30) Group S, CA (n = 37) pa GSI À0.39 Æ 0.72 À0.45 Æ 0.69 ns À0.48 Æ 0.79 À0.49 Æ 0.72 ns GAF 7.59 Æ 15.98 12.83 Æ 19.26 ns 9.16 Æ 16.35 13.57 Æ 20.74 ns GLQ 0.91 Æ 1.72 0.83 Æ 1.26 ns 0.90 Æ 1.45 0.97 Æ 1.36 ns RCQ-general 0.56 Æ 0.94 0.65 Æ 1.35 ns 0.85 Æ 1.12 0.65 Æ 1.38 ns RCQ-relation 0.28 Æ 1.03 0.24 Æ 0.90 ns 0.43 Æ 1.23 0.23 Æ 0.96 ns Note. GSI = Global Severity Index from SCL-90-R; GAF = Global Assessment of Functioning; GLQ = Global Life Quality; RCQ = Registration Chart Questionnaire; ITT = intention to treat analysis; CA = completer analysis. a Independent-samples t-test. 200 Henriette Elkjaer et al.
  • 11. 52 vs. Group S: 20/54; OR 0.36, 95% CI 0.14–0.88, p = .025). When looking at change on the RCI for the GSI from pre-treatment to the 1-year follow-up, nine patients (9%) had deteriorated (Group A: 5/52 vs. Group S: 4/54; OR 1.33, 95% CI 0.34–5.25, p = .684), three of those both statistically and clinically (Group A: 1/52 vs. Group S: 2/54; OR 0.51, 95% CI 0.04–5.80, p = .587), 51 patients (48%) remained unchanged (Group A: 26/52 vs. Group S: 25/54; OR 1.16, 95% CI 0.54–2.48, p = .703), and 46 patients improved (Group A: 21/52 vs. Group S: 25/54; OR 0.79, 95% CI 0.36–1.70, p = .540), 30 of those both statistically and clinically (Group A: 13/52 vs. Group S: 17/54;OR0.736, 95% CI 0.31–1.70, p = .460). In supplementary analyses, we tested potential moderator effects on change by the following factors: Five or more sessions during follow-up period, severity of abuse, perceived social support in childhood, perceived social support in adulthood, and previous psychiatric treatment. The models included the main effect of group, the main effect of each potential moderator variable, and the interaction between the group factor and the moderator variable. Analyses were conducted of both unadjusted change scores and of change scores adjusted for baseline GSI scores, and for both sets of analyses no significant interactions were observed. Discussion The results of this study indicate that the courses of the two groups differed significantly on most measures from pre-treatment to follow-up. Outcome was more pronounced and significantly better for Group S during treatment, but decreased during follow-up. Therefore, 1 year after treatment completion, Group A and Group S treatments did not differ significantly with respect to improvement in general symptoms, psychosocial functioning, quality of life, and occurrence of flashbacks in women with a history of intra-familial CSA. Thus, our hypothesis that outcomes of Group S therapy would remain superior to outcomes of Group A therapy at the 1-year follow-up was not supported. Table 4. Flashbacks (intention to treat analyses), Group A (n = 49) versus Group S (n = 51)a Pre-score N Post-score N 1-Year follow-up N Signb Pre-post Signb Post-1-year Group A ns p .01 More than 4 per month 32 27 12 1–4 Per month 4 9 21 1 Per month 10 10 13 n 46 46 46 Group S p .001 ns More than 4 per month 39 15 10 1–4 Per month (%) 6 21 21 1 Per month 6 15 20 n 51 51 51 Test between groups v2 = 0.258 ns v2 = 4.722 ns v2 = 6.206 p .05 Note. a Missing data on six patients from Group A and three from Group S. b Stuart’s test of equality. 1-Year follow-up of a randomized trial 201
  • 12. Support was found for the hypothesis of maintenance of gains as statistically significant improvements are maintained on all measures from pre-treatment until 1 year after treatment completion for both patients receiving Group A and Group S psychotherapy. This is in accordance with other follow-up studies (range of follow-up periods: 6 months to 4.7 years; median: 8 months) (Alexander et al., 1989; Dorrepaal et al., 2010; Edmond Rubin, 2004; Lorentzen, Bøgwald, Høglend, 2002; Lundqvist, Svedin, Hansson, Broman, 2006;McDonaghet al., 2005;Richteret al., 1997;Ryan, Nitsun, Gilbert, Mason, 2005; Saxe Johnson, 1999; Stalker Fry, 1999; Stalker, Palmer, Wright, Gebotys, 2005; Talbot et al., 1999; Vaa, Egner, Sexton, 2002). Among these studies, five of six studies using SCL-90 report GSI mean and standard deviation. When calculating GSI effect sizes for the follow-up period exclusively, two of the structured treatment modalities (Stalker et al., 2005; Talbot et al., 1999) demonstrated maintenance of gains during follow-up (ES = À0.15 and 0.13, respectively), whereas one (Alexander et al., 1989) demonstrated decrease in gains during follow-up (ES = À0.32), similar to our Group S (ES = À0.24). Of the groups within a less directive approach, two (Alexander et al., 1989; Lundqvist et al., 2006) demonstrated maintenance of gains during follow-up (ES = 0.11 and À0.01), similar to our Group A (ES = 0.09), whereas two (Lorentzen et al., 2002; Lundqvist et al., 2006) demonstrated ongoing positive change during follow-up (0.23, and 0.24, respectively). A possible explanation for the difference in trajectories between the two treatment modalities may be found in the different frames for treatment, such as the level of structure in the sessions and the frequency of group meetings (Lau Kristensen, 2007, 2012) or in differences in therapeutic focus and interventions. The influence of structure on outcome is discussed in a review of interpersonal-psychodynamic group psychotherapy outcomes (Callahan, Price, Hilsenroth, 2004). By calculating effect-size indicators between pre-treatment and 6-month follow-up data from another randomized trial (Alexander et al., 1989) Callahan et al. found preliminary evidence that a more structured interpersonal transaction group showed considerably greater long-term improvement across all measures as compared to a less structured interpersonal process group. They proposed that women with a history of CSA might fare better in interpersonal groups which incorporate some structure to group processes. Our data support the position of Callahan et al. regarding immediate outcome, but not regarding long-term effect. Our results indicate that when the external structured and supportive setting was no longer present, Group S participants had difficulty maintaining gains. Group S treatment focused directly on symptoms and on the narratives participants told about themselves and their lives. An integrated part of this solution-focused approached is to help patients construct solutions to problems frequently experienced by patients with a history of CSA, such as flashbacks, feelings of guilt, and problems trusting ones own judgements (Holme, 1999). Due to the structure, Group S participants might have been able to work on issues related to their symptoms more quickly, leading to significantly better outcomes during treatment (Lau Kristensen, 2007). The slower but more stable progress in Group A could be due to the unstructured and prolonged treatment course in this group or it could be that change in relationships manifests itself gradually and keeps evolving, even after the termination of treatment. It is likely that the less structured setting more closely mirrors the diversity and ambiguity of interactions of real life, and thus provides a learning process on how to navigate in interpersonal relationships outside the therapeutic setting and enable the patients to consolidate new behaviours over time. Despite statistically significant improvement during treatment, more than one-half of the patients in the current study remained above cut-off for caseness on GSI by the end of 202 Henriette Elkjaer et al.
  • 13. treatment and at the 1-year follow-up, which indicates a need for further treatment. Since the number of sessions in both treatments was not solely determined by remission of symptoms, but also relied on the given resources, it is possible that longer term treatments would have entailed a better overall outcome. Almost one third of the treatment completers attended additional treatment during follow-up. However, even though approximately twice as many in Group A were above cut-off on GSI post-treatment as compared to Group S, the amount of treatment during follow-up for the two groups was equivalent. Therefore, the different outcomes during follow-up cannot be attributed to additional treatment alone. More randomized studies with long-term follow-up are needed to determine the main factors that produce faster alleviation of suffering and/or longer duration of effect: theoretical approach (e.g. solution-focused vs. interpersonal), frequency of meetings, or duration of treatment (short term vs. long term). To account for the effect of patients not having their primary preference as the allocated intervention (Lau Kristensen, 2007), randomized trials with patient-preference design could be considered. Based on the findings in this study, phase-divided treatment might also be an area of future investigation. In this study, Group S demonstrated greater alleviation of symptoms during treatment as compared to Group A, but gains decreased after termination whereas Group A participants maintained gains during follow-up. It is thus likely that the different treatment modalities might complement each other at different stages of treatment that is starting out with a structured approach for faster alleviation of suffering and continuing with a less structured approach to promote maintenance of gains/ongoing positive change after termination. Another possible area for future studies is the relationship between treatment modality and post-treatment trajectory. Knowledge within this area is very sparse, and more research is needed of whether various treatment modalities leads to continued or decreased gains post-treatment or whether it is specific treatment factors which enhances/decreases effects after treatment. This is important both for ethical reasons, and to prevent relapse and improve long-term effects. Still another field of future investigation might be treatment tailored for various combinations of symptom profiles focusing on which treatment is most efficient for whom (Taylor Harvey, 2010). In our study, the outcomes of Group A and Group S were equivalent at the 1-year follow-up. But as the sequelae of CSA are not manifested in one specific syndrome but rather as a variety of symptoms, ranging from depression, PTSD, and eating disorders to various personality disorders, the outcome might be enhanced by treatments tailored to each CSA-patients’ specific symptom profile. A potential limitation of this study is the difference in group format. Group A participants met once a week (2.25 hr/week) for 12 months, whereas Group S participants met twice a week (5 hr/week) for 5 months. Thus, even though participants received approximately the same amount of treatment, it is possible that it is the intensity in meeting frequency rather than the therapeutic techniques that explains the different trajectories during and after treatment. On the other hand, it might be argued that within the given resources, the differences in treatment format closely reflect the established practices within two bone fide treatment approaches. Accord- ingly, the variations in group format may actually contribute to the external validity to the study. Another limitation is that a power analysis, specifically aimed at the follow-up study, was not conducted at the onset of the study. Thus, further attrition and the potential decrease in observed effects in the follow-up-period was not taken into account when deciding the sample size of the study. Furthermore, measures of the 1-Year follow-up of a randomized trial 203
  • 14. presence of PTSD and major depression have not been included in this 1-year follow-study. Conclusion Rapid minimization of psychological suffering is an important goal at the start of treatment. However, maintaining the effect over time may be of even greater value for preventing the long-term negative problems related to CSA. The results of this study indicate that time-intensive solution-focused treatment boosted patient progress and provided faster alleviation of suffering during treatment, but that gains decreased during follow-up. The prolonged less directive analytic approach resulted in slower alleviation of suffering during treatment, but gains were maintained during follow-up. Longer term follow-up data are required to evaluate whether gains are maintained for more than 1 year and to illuminate the long-term trajectories of the two treatment groups. Future research should investigate whether phase-divided treatment or tailored treatment would result in even better short- and long-term reductions of suffering in this population. Acknowledgements We thank the women participating in this study. This study was made possible by grants from The Danish Council for Independent Research | Medical Sciences, The East Danish Research Foundation; Butcher Wørzner and Wife Inger Wørzner’s Memorial Grant in Favour of Research in Mental Disorders; The Health Insurance Foundation; and Aase Ejnar Danielsen’s Foundation. For statistical assistance, we thank Helge Gydesen, Health Care Development, Novo Nordisk A/S. We thank Susanne Reinhardt for linguistic assistance. References Akyuz, G., Sar, V., Kugu, N., Dogan, O. (2005). Reported childhood trauma, attempted suicide and self-mutilative behavior among women in the general population. European Psychiatry, 20, 268–273. doi:10.1016/j.eurpsy.2005.01.002 Alexander, P. C., Neimeyer, R. A., Follette, V. M., Moore, M. K., Harter, S. (1989). A comparison of group treatments of women sexually abused as children. Journal of Consulting and Clinical Psychology, 57, 479–483. doi:10.1037/0022-006X.57.4.479 American Psychiatric Association. (2000a). Diagnostic and statistical manual of mental disorders. DSM-IV-TR (4th ed., text revision ed.). Washington, DC: American Psychiatric Association. American Psychiatric Association. (2000b). Handbook of psychiatric measures (1st ed.). Washington, DC: The Author. Arata, C. M. (2002). Child sexual abuse and sexual revictimization. Clinical Psychology-Science and Practice, 9, 135–164. doi:10.1093/clipsy.9.2.135 Avery, L., Hutchinson, K. D., Whitaker, K. (2002). Domestic violence and intergenerational rates of child sexual abuse: A case record analysis. Child and Adolescent Social Work Journal, 19, 77–90. doi:10.1023/A:1014007507349 Bebbington, P. E., Cooper, C., Minot, S., Brugha, T. S., Jenkins, R., Meltzer, H., Dennis, M. (2009). Suicide attempts, gender, and sexual abuse: Data from the 2000 British Psychiatric Morbidity Survey. American Journal of Psychiatry, 166, 1135–1140. doi:10.1176/appi.ajp.2009. 09030310 204 Henriette Elkjaer et al.
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