Effects of current treatments for trauma survivors with posttraumatic stress disorder on reducing a negative self-concept: a systematic review and meta-analysis

Figures & data

Figure 1. PRISMA Flowchart.

Table 1. Study characteristics coded.

Participants	Psychological intervention	Control group	NSC instrument
N randomised Female % Age M(SD)	Cognitive restructuring (yes/no)^a Cognitive restructuring of explicitly self-related cognitions (yes/no)^a Type of therapy CT/CBT Exposure alone EMDR Other types of therapy Trauma-focused (yes/no)	Type of control group Inactive control (waiting list or no contact control group) Active control (psychological placebob or TAU^c). Other psychological intervention	Type of NSC instrument Trauma-related cognitions about the self Non-trauma-related cognitions about the self Guilt and shame cognitions

Notes. NSC = negative self-concept. CT/CBT = Cognitive Therapy / Cognitive Behavioral Therapy. EMDR = Eye Movement Desensitisation and Reprocessing.

^a In order to rate this criterion, we first checked the study protocol/manual used for the trial. If this was not available or did not contain this information, we consulted a standard manual for the treatment that was investigated (e.g. Shapiro, 2017, in the case of EMDR).

^b Psychological placebo is defined as a non-specific psychological intervention, such as repeated symptom assessments.

^c TAU ( =  treatment as usual) is defined as the treatment that patients would usually have received.

Figure 2. Forest plot of between-group effect sizes (post-treatment). Notes. SMD refers to the comparison between the intervention and control groups at post-treatment; measure used is Hedges’ g; positive values refer to cases where the intervention group had a better averaged NSC value than the control group at post-treatment. NNT

 = Number Needed to Treat (NNT with negative sign refers to Number Needed to Harm, NNH). CPT = Cognitive Processing Therapy. PE = Prolonged Exposure.

Table 2. Results of meta-analyses.

Part A. Effect of Interventions on negative self-concept
Analysis	k	g	95%CI	p	NNT		NNH
					Range	M (SD)	Range	M (SD)
Meta-analysis with all types of control groups	30	0.67	0.31, 1.02	<.001	1, 13	4.72 (3.54)	−30, −6	−16.00 (10.07)
Meta-analysis with inactive control	19	0.68	0.28, 1.09	<.001	1, 13	4.56 (3.54)	−30, −10	−21.00 (10.15)
Meta-analysis with active control	11	0.65	−0.15, 1.45	.102	1, 13	5.00 (3.74)	−11, −6	−8.50 (3.54)
Part B. Moderator Analyses
Analysis	k	g	95%CI	p	I^2	95%CI		pSubgroup
Cognitive restructuring								.187
Yes	15	0.91	0.23, 1.59	.012	88.20%	82.20%, 92.20%
No/unclear	15	0.45	0.11, 0.78	.013	69.50%	48.10%, 82.00%
Cognitive restructuring of explicitly self-related cognitions								.634
Yes	9	0.78	0.02, 1.54	.046	86.20%	75.80%, 92.10%
No/unclear	6	1.13	−0.57, 2.83	.148	91.50%	84.20%, 95.40%
Part C. Exploring Heterogeneity
Analysis	k	G	95%CI	P	95%CI	I^2	95%CI	pSubgroup
Meta-analysis	30	0.67	0.31, 1.02	<.001	−1.06, 2.39	82.70%	76.20%, 87.40%	–
Meta-analysis excluding influential cases^a	27	0.42	0.25, 0.58	<.001	−0.26, 1.09	60.60%	14.00%, 74.10%	–
Sensitivity analyses on the type of NSC instrument								.264
Trauma-related cognitions about the self	9	1.01	0.01, 1.93	.035	−1.70, 3.71	84.90%	73.10%, 91.50%
Non-trauma-related cognitions about the self	11	0.34	−0.14, 0.82	.145	−1.07, 1.75	71.10%	46.70%, 84.40%
Guilt/shame cognitions	10	0.73	0.04, 1.43	.040	−1.38, 2.86	86.70%	77.50%, 92.10%

Notes. Inactive control = waiting list or no contact control group. Active control = psychological placebo or treatment as usual (TAU). NNT = number needed to treat. NNH = number needed to harm.

^a Studies removed as influential cases: Alsheikh Ali (2020), Kubany et al. (2003), Molavi et al. (2020).

Figure 3. Weighted risk of bias of all studies (k = 25) assessed according to the Cochrane Risk of Bias Assessment Tool (Higgins et al., 2011).

Shapiro, F. (2017). Eye movement desensitization and reprocessing (EMDR) therapy. Guilford.

 Google Scholar

Alsheikh Ali, A. S. S. (2020). Efficiency of intervention counseling program on the enhanced psychological well-being and reduced post-traumatic stress disorder symptoms Among Syrian women refugee survivors. Clinical Practice and Epidemiology in Mental Health, 16(Suppl-1), 134–141. https://doi.org/10.2174/1745017902016010134

 PubMedGoogle Scholar

Kubany, E. S., Hill, E. E., & Owens, J. A. (2003). Cognitive trauma therapy for battered women with PTSD: Preliminary findings. Journal of Traumatic Stress, 16(1), 81–91. https://doi.org/10.1023/A:1022019629803

 PubMed Web of Science ®Google Scholar

Molavi, P., Pourabdol, S., & Azarkolah, A. (2020). The effectiveness of acceptance and commitment therapy on posttraumatic cognitions and psychological inflexibility among students with trauma exposure. Archives of Trauma Research, 9(2), 69–74. https://doi.org/10.1016/j.beth.2010.08.009

 Web of Science ®Google Scholar

Higgins, J. P., Altman, D. G., Gøtzsche, P. C., Jüni, P., Moher, D., Oxman, A. D., Savovic, J., Schulz, K. F., Weeks, L., & Sterne, J. A. (2011). The Cochrane collaboration's tool for assessing risk of bias in randomised trials. BMJ, 343(oct18 2), d5928. https://doi.org/10.1136/bmj.d5928

 PubMed Web of Science ®Google Scholar