Most studies reported that study therapists had at least master’s level training and frequently held doctorates in psychology, clinical psychology, or clinical social work. Only one study used therapists with less then graduate training but considerable counseling experience, and a few studies used graduate students. Most studies used psychologists, but several studies also used marriage and family counselors (MFCCs), licensed clinical social workers, and one study also used nurses. The majority of studies reported that study therapists were trained and supervised.

The majority of exposure therapy studies did not report on or measure adverse events associated with their treatment condition. Only Monson et al. (2006), Foa et al. (2005), Schnurr et al. (2007), and Chard (2005) measured adverse events.

Many studies conducted follow-up after the completion of treatment. The earliest timing of follow-up assessments was 1 month, and the latest was between 1 and 2 years after treatment. Some studies took follow-up measures at 3, 6, and 9 months post-treatment.

Of the 23 studies in this category, 16 had major limitations including high dropout rates,2 absent or weak treatment of missing values, lack of assessor independence, not conducting an intention to treat analysis, or failure to report a critical characteristic (Blanchard and Hickling, 2004; Boudewyns et al., 1993; Classen et al., 2001; Cloitre et al., 2002; Falsetti et al., 2001; Foa et al., 1991, 1999, 2005; Glynn et al., 1999; Keane et al., 1998; Kubany et al., 2003, 2004; McDonagh et al., 2005; Power et al., 2002; Resick et al., 2002; Rothbaum et al., 2005). Eight studies met most or all of the quality criteria outlined in Chapter 2 (the main shortcoming in two of these studies was in the handling of substantial dropout rates with less robust statistical methods and or assessor blinding or independence) (Basoglu et al., 2005, 2007; Chard, 2005; Fecteau and Nicki, 1999; Hinton et al., 2005; Keane et al., 1989; Monson et al., 2006; Rothbaum et al., 2005). All eight of these studies demonstrated a statistically significant improvement with treatment to a primary PTSD scale or to the loss of PTSD diagnosis. One of these studies with no major limitations in male veterans with chronic PTSD showed both reductions in a primary PTSD scale and the loss of PTSD diagnosis with cognitive processing therapy (a combination of exposure and cognitive restructuring) (Monson et al., 2006).

The committee identified eight additional RCTs comparing exposure therapies to an active control (coping skills training program or present-centered therapy). Four of the studies had major limitations, such as high dropout rates and either presenting only a completer analysis or using last observation carried forward (LOCF) despite dropout rates of up to


The APA (2004) review of the literature identifies high rate of dropout as a challenge of exposure therapies.

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