Avoidant Coping and Treatment Outcome in Rape-Related Posttraumatic Stress Disorder

Posttraumatic Stress Disorder (PTSD) is characterized by the development of reexperiencing, avoidance, numbing, and hyperarousal symptoms following exposure to a traumatic event (American Psychiatric Association, 2000). Raped women comprise the largest proportion of PTSD sufferers, which is estimated at 8% in the general population (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). A number of psychotherapies have proven effective for PTSD including exposure therapy, stress inoculation training, and eye movement desensitization and reprocessing (EMDR) (Chambless et al., 1998). The International Society for Traumatic Stress Studies found the strongest evidence for cognitive behavioral techniques (CBT; Foa, Keane, Friedman, & Cohen, 2009), and of the CBT techniques studied, prolonged exposure (PE) had the most evidence for its efficacy from the most well controlled studies (Cahill, Rothbaum, Resick, & Follette, 2009). Despite the availability of effective psychotherapies, a significant minority of women with rape-related PTSD do not respond to these treatments. In four studies of rape victims treated with empirically supported therapies (Foa, Rothbaum, Riggs, & Murdock, 1991; Resick, Nishith, Weaver, Astin, & Feuer, 2002; Rothbaum, 1997; Rothbaum, Astin, & Marsteller, 2005), 41% of those who started psychotherapy and 23% of those who completed psychotherapy continued to meet criteria for PTSD at the end of treatment. Given these rates of nonresponse, it is particularly important to understand who is likely to respond to psychotherapy and why. One way to predict who may benefit from PTSD treatment is to investigate variables that impact naturalistic recovery from rape. One such variable is a woman’s coping response. Although potential coping responses may be varied and complex, all may be conceptualized as approach or avoidance methods (Roth & Cohen, 1986). Research suggests that raped women use both methods to some extent, but only avoidant coping is consistently associated with variability in recovery. Specifically, avoidant coping is related to poorer psychological adjustment (Cohen & Roth, 1987; Santello & Leitenberg, 1993) and more severe PTSD symptoms (Boeschen, Koss, Figueredo, & Coan, 2001; Valentiner, Foa, Riggs, & Gershuny, 1996). In their seminal paper on coping, Roth and Cohen (1986) defined avoidant coping as cognitive and emotional activity oriented away from threat. Avoidant coping generally reduces immediate stress but may disrupt daily life, lead to emotional numbness, and interfere with more appropriate action. Avoidant coping responses to rape have been characterized as attempts to “block out memories of [the] rapes or minimize or rationalize [the] rape experiences” (Boeschen et al., 2001, pp. 211) or as wishful thinking that encompasses “self blame and denial by fantasy” (Valentiner et al., 1996, p. 457). There may be theoretical and real overlap between avoidant coping and avoidance symptoms of PTSD, but studies of naturalistic recovery have not accounted for this potential confound. If we assume that the process of naturalistic recovery is similar to the process of treatment recovery, then we would hypothesize that higher levels of avoidant coping are related to more severe PTSD symptoms after treatment. However, the process of naturalistic recovery and treatment recovery may not be similar. In fact, cognitive-behavioral theories of PTSD and its treatment (e.g., Foa, Steketee, & Rothbaum, 1989; Harvey, 1999) posit that recovery is associated with decreases in trauma-related avoidance. Both PE and EMDR encourage engagement with traumatic memories, a behavior incompatible with trauma-related avoidance. Therefore, women who use avoidant coping strategies to deal with rape before treatment may be particularly good candidates for PE or EMDR and may benefit more from these therapies than woman who do not rely as heavily on avoidant coping strategies. If this suggestion is true, then high levels of avoidant coping would be associated with lower levels of PTSD symptoms following treatment. Thus the purpose of the current study was to investigate two competing hypotheses regarding the impact of avoidant coping on treatment outcome in rape-related PTSD. The first hypothesis, based on naturalistic recovery from PTSD, was that pretreatment avoidant coping would be positively associated with posttreatment symptom severity. That is, more avoidant coping before treatment would predict more PTSD symptoms following treatment and vice versa. The second hypothesis, based on cognitive-behavioral theories of PTSD and its treatment recovery, was that pretreatment avoidant coping would be negatively associated with posttreatment symptom severity. Specifically, higher levels of avoidant coping before treatment would predict less severe PTSD symptoms after treatment and vice versa. If we found a significant relationship (in either direction) between pretreatment avoidant coping and posttreatment symptom severity, we planned an exploratory analysis. The exploratory analysis would utilize logistic regression to estimate the likelihood of responding to treatment given pretreatment avoidant coping scores. Such an analysis would help clinicians determine which individuals with PTSD would be likely to benefit from treatment.