A combination treatment of Well-being Therapy and Trauma-Focused Therapy for patients with PTSD

The lifetime prevalence of post-traumatic stress disorder (PTSD) in the
Netherlands has been estimated on 7.4%. Treatment for PTSD is necessary because
left untreated, PTSD can become a chronic condition that engenders long-term
social and functional impairment. From a societal perspective, mental illness
is costly, often resulting in diminished productivity and increased rates of
service utilization. In the Mental Health Care Institutions in The Netherlands,
the overall focus for treating PTSD is to reduce symptoms of PTSD as
recommended in the Clinical Practice Guideline (2017) for Psychotrauma and
Stressrelated Disorders and subscribed by the newest Health Care Standard for
Psychotrauma and Stressrelated Disorders (in press, Klaassen, et.al.). During
those trauma-focused treatments (TFT), less attention is given to increase the
mental well-being of people with PTSD right at the beginning of the treatment.
According to the World Health Organization (WHO, 2001), health cannot be
defined as the absence of disease or infirmity but needs to be defined as a
state of complete physical, mental and social well-being. There is a growing
interest for positive psychology interventions (PPIs) in clinical settings,
wherein the focus is on eliciting positive feelings, cognitions or behaviors. A
recent review shows that PPIs in clinical settings not only have the potential
to improve well-being, but can also reduce distress in populations with
clinical disorders. Another important issue in relation to TFT is the level of
drop out. Although TFTs have been shown to be effective for PTSD, 36% of
individuals with PTSD drop out of these exposure-based treatments. In the
clinical practice patients with PTSD are treated as subscribed by the Clinical
Practice Guideline and Health Care Standard mainly focused on reducing symptoms
right at the beginning of the treatment but not on (1)strengthening the mental
well-being nor on (2) decreasing the drop out rates. Well-being therapy (WBT)
is a novel psychotherapeutic intervention with the aim to improve a healthy and
individualized path to positive mental health. This therapy can have a superior
effect on both, the well-being and the drop out rate when offered at the
beginning. WBT has been employed in several clinical studies where-in
researchers combined WBT with cognitive behavior therapies with result. One
recent study in the Netherlands added WBT to the end of the treatment for
patients with PTSD, when PTSD symptoms have already been decreased. Yet, no
studies have investigated the combination of WBT with TFT right at the
beginning of the treatment, with the aim of strengthening the well-being and
reducing symptoms.

The current study aims to assess the effectiveness of added WBT to TFT
(combined sessions of individual WBT and individual TFT during the first 6
months) at the beginning of the treatment for people with PTSD on mental
well-being compared to care as usual (CAU), which is individual TFT. It is
hypothesized that the combination treatment WBT+TFT at the beginning is
superior compared to CAU on the mental well-being, the severity of PTSD
symptoms, the rates for drop out for any reason, psychological well-being and
severity of depressive and anxiety symptoms.

A randomised, controlled intervention study with two conditions. Measurements
take place at baseline, at mid treatment and after treatment.

The present study will be the first study to examine the combination of
individual TFT with WBT for patients with PTSD. The participants will get
combined sessions of WBT and TFT during the first 6 months. The participants
will get the same 12 individual TFT interventions (12 individual sessions, 45
minutes) as in the CAU but combined with 6 individual sessions of WBT (45
minutes every two weeks). The WBT consists of 6 individual sessions of 45
minutes each using a structured protocol which are given in-between TFT
sessions. The participants of the control group will receive care at usual
(CAU): 12 individual TFT sessions (45 minutes).

The duration of the study will be around 6 months for each individual from
baseline to completion of the treatment. During this study, participants
complete three assessments of approximately 30 minutes each. Additionally, the
experimental group will have 6 added WBT sessions (45 minutes each) to TFT
compared to CAU. Every 2 weeks they will have a combined WBT +TFT session,
which implies 45 minutes extra to the TFT session. Participants in the
experimental group will spend approximately 5-10 additional minutes a day
exercising at home in these 6 months, during the 6 weeks wherein they receive
the combination treatment WBT +TFT (6 weeks * 10 minutes a day = 420 minutes in
total for additional homework)' Participants are free to participate in the
study. Subjects can leave the study at any time for any reason if they wish to
do so without any consequences. The therapists can decide to withdraw a subject
from the study for urgent medical reasons. All therapists are well trained in
both treatments and will participate in intervision sessions during the study.