Response of African American and Caucasian Women to Cognitive Behavioral Therapy for PTSD

Reviewed by
Priscilla Schulz, LCSW
from an article of the same title by:
Lori A. Zoellner, Norah C. Feeny,
Lee A. Fitzgibbons, and Edna B. Foa,
University of Pennsylvania School of Medicine

Published: Behavior Therapy, V. 30, 581-595, 1999

Background
A body of professional literature documents differences between African Americans and Caucasian Americans with regard to posttraumatic stress disorder (PTSD). Compared to Caucasian Americans with similar profiles research finds that African Americans

• report more chronic PTSD symptoms after natural disasters (Green Grace, Lindy, & Leonard, 1992),
• demonstrate greater susceptibility to developing PTSD (Norris, 1992),
• have more severe cases of PTSD, seek treatment more, but drop out sooner (Sue, 1977),
• use mental health facilities more, but exhibit less positive results from mental health services (Sue, Fujino, Hu, Takeuchi, and Zane, 1991),
• and among Vietnam Veterans (Kulka et al., 1990) evidence higher rates of PTSD than Caucasian veteran counterparts.

Researchers suggest that differences in economic factors between African Americans and Caucasian Americans, and higher levels of exposure to trauma in the lives of African Americans may explain these results.

Not all studies comparing African Americans and Caucasian Americans with regard to PTSD find differences between the groups. For example, one study (Wyatt, 1992) looked at the long-term effects of sexual assault among African American and Caucasian American, female, rape survivors. The Wyatt study found similar levels of long-term disturbances in both groups as a result of the rape. In short, the presence of contradictory results from research make it unclear whether or not ethnocultural factors affect PTSD development and a client’s ability to benefit from known PTSD treatments.

What is the scope of this study?
In the present study, researchers looked at the effectiveness of time-limited, cognitive behavioral treatment for PTSD with female survivors of assault, (i.e., sexual assault and nonsexual, aggravated assault). They examined whether or not there were differences between African American and Caucasian American study participants before treatment (e.g., differences in worldview, psychopathology, social functioning, coping style and social support), and in their response to treatment. Researchers also looked at other factors noted in previous studies, such as treatment dropout rates and socio-economic status.

How was the study conducted?
Ninety-five assault survivors participated in the study. All had PTSD, but none currently lived with an abusive partner, or suffered from organic mental disorder, schizophrenia, bipolar disorder or substance dependence. There were more Caucasian American than African American participants (63% vs. 37%), and the groups differed demographically; African American participants had lower incomes, fewer were employed and they had less education than their Caucasian American counterparts. In addition, fewer of the African American participants had sought treatment for the assault. Ethnic groups were similar with regard to marital status and prior abuse histories, and the average age was 35 years.

Researchers used both structured interviews and self-report measures to assess degree of psychological disturbance (including depression, anger, anxiety, worldview and PTSD), and to measure improvements or changes that resulted from the cognitive-behavioral intervention. Three different treatments were used in the study (i.e., prolonged exposure-PE, stress inoculation training-SIT, combined prolonged exposure plus stress inoculation-PE+SIT), and compared to a control group of participants on a treatment wait list. Doctoral-level, Caucasian American, female therapists conducted all treatment sessions.

What were the study’s findings?

Similarities

No significant differences were found between Caucasian American and African American study participants on

• pretreatment measures of mental well being (psychopathology, anger, avoidance or social functioning),
• persistence in continuing with treatment (dropout rates),
• and in reports of improvements from participating in treatment.

Differences

• Caucasian American and African American participants differed significantly in their beliefs about the world after the assault. Specifically, Caucasian Americans reported that their outlook became bleaker after the assault, but this was not so for African Americans. Of note is the fact both groups reported similar world-views before the assault.

Other Findings

• Compared to the waiting list condition, all three treatment conditions, PE, SIT, and PE+SIT, were similarly effective with both ethnic groups and across all income levels of study participants.
• Participants with lower scores on beliefs about the world’s benevolence had more severe PTSD symptoms at pretreatment.
• Treatment significantly improved psychological well being of study participants.

Reviewed by Priscilla Schulz, LCSW, September 18, 2000