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Program Profile: Trauma Affect Regulation: Guide for Education and Therapy (TARGET)

Evidence Rating: Effective - More than one study Effective - More than one study

Date: This profile was posted on June 09, 2011

Program Summary

A manualized, trauma-focused psychotherapy for adolescents and adults suffering from posttraumatic stress disorder. The program is rated Effective. There were significant reductions in measures of PTSD symptoms and anxiety for the treatment group compared to the control group.

Program Description

Program Goals/Target Populations
Trauma Affect Regulation: Guide for Education and Therapy (TARGET) is a manualized, trauma-focused psychotherapy for adolescents and adults suffering from posttraumatic stress disorder (PTSD). TARGET teaches skills for processing and managing trauma-related reactions to stressful situations, such as PTSD symptoms, traumatic grief, survivor guilt, and shame. The goal of treatment is to help individuals regulate intense emotions and gain control of posttraumatic stress reactions.

Program Components

TARGET’s three main components can be delivered through group or individual therapy. These components include:
  • Education about the biological and behavioral components of SUDs and PTSD
  • Guided implementation of information/emotion processing and self-regulation skills (see information on the FREEDOM skill sequence below)
  • Development of an autobiographical narrative that incorporates the trauma and PTSD

In its brief therapy form, individuals receive counseling in 12 weekly sessions. But treatment can sometimes last between 6 months and several years.

Therapy focuses on the client’s core values and hopes, resilience, and client strengths. Therapists reframe PTSD symptoms as healthy reactions to abnormal circumstance; in other words, the symptoms are a sign that the individual has coped well with the trauma. Clients learn that they can reset this “biological alarm” (Ford and Russo 2006, 342), which does not serve the individual well in ordinary life.

The program introduces a seven-step skill sequence—known by the acronym FREEDOM—that helps individuals learn to process and manage trauma-related reactions to stressful current situations. These steps are:

  • Focus. A step to reduce anxiety and increase mental alertness.
  • Recognize. An activity to help individuals recognize specific stress triggers.
  • Emotions. A step to identify primary feelings.
  • Evaluate. A step in which individuals evaluate main thoughts/self-statements.
  • Define. An activity to help individuals determine and define their main personal goal(s).
  • Option. An activity where individuals identify one choice that represents a successful step toward the main goal(s) that he or she actually accomplished during a current stressful experience.
  • Make a contribution. An activity to help individuals recognize how that option reflected their core values and made a difference in others’ lives.
These skills are introduced through the three phases of treating PTSD. Phase 1 coincides with the “F” (Focus) skill; phase 2 primarily focuses on recognition skills, and includes the skills represented by “REEDOM”; and phase 3 involves the incorporation of these skills into the individual’s overarching goals.

Program Theory
TARGET draws on cognitive­–behavioral therapy and self/relational models of treatment to define a set of steps for clients to learn how to regulate intense emotions and solve social problems while simultaneously maintaining sobriety. It provides a framework for understanding and managing trauma memories and affecting dysregulation.

Evaluation Outcomes

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Study 1
Posttraumatic Stress Disorder (PTSD) Symptoms
Compared to the waitlist control participants (classified as treatment as usual, or TAU), Ford and colleagues (2008) found that both Trauma Affect Regulation: Guide for Education and Therapy (TARGET) and Present Centered Therapy (PCT) participants experienced reductions in PTSD symptoms, with TARGET participants experiencing larger reductions. Absolute levels of PTSD symptoms were reduced by 33 percent for the TARGET participants, so that mean levels fell below the clinical range cut-off score. At both follow-up assessments, PTSD severity scores were reduced to a level more than 50 percent lower than baseline. Between posttherapy and the 6-month follow-up, the incidence of full or partial PTSD decreased significantly for TARGET participants compared to TAU participants.

Negative Mood Regulation
Both treatment conditions experienced decreased negative mood regulation compared to TAU participants. Compared to the TAU group, TARGET led to a statistically significant improvement in negative mood regulation. TARGET participants experienced greater improvements than PCT participants.

Trauma-Related Beliefs
Compared to the TAU group, TARGET led to a statistically significant reduction in trauma-related beliefs. These improvements were sustained through the 6-month follow-up.

Distress Related to PTSD
Compared to the TAU group, TARGET led to a statistically significant reduction in distress related to PTSD. These improvements were sustained through the 6-month follow-up.

Depression
Compared to TAU, PCT led to larger statistically significant reductions in depression than TARGET. For the TARGET group, however, scores continued to decline through the 6-month follow-up. By the 6-month follow-up, TARGET was associated with equivalent sustained reductions in depressive symptoms compared to PCT.

Anxiety
Compared to the TAU group, TARGET led to a statistically significant reduction in anxiety. Scores remained low, below clinical cut-point, at the 6-month follow-up.

Study 2
Overall, the study by Ford and colleagues (2012) found that TARGET was associated with significant reductions in measures of PTSD symptoms, anxiety, and posttraumatic cognitions compared with the Enhanced Treatment as Usual (ETAU) group. However, the ETAU group showed better improvements on measures of optimism/self-efficacy and reduced anger.

PTSD Symptoms
Compared with the ETAU group, participants in TARGET showed significantly greater reductions in PTSD symptoms as measured by the Clinician-Administered PTSD Scale for Children/Adolescent. Specifically, at the 4-month follow-up there were significant reductions for the TARGET in measures of PTSD Criteria B symptoms (intrusive reexperiencing) and Criteria C symptoms (avoidance and emotional numbing) compared with the ETAU group. There was also a significant reduction for the TARGET group in the measure of total PTSD symptoms. However, there was no difference between the groups on PTSD Criteria D symptoms (hyperarousal).

Negative Mood Regulation
There were no differences between the TARGET and ETAU groups on measures of negative mood regulation.

Posttraumatic Cognitions
There were significant improvements for the TARGET group on measures of posttraumatic cognitions compared with the ETAU comparison group.

Optimism/Self-Efficacy
The ETAU comparison group showed significant gains in measures of optimism and self-efficacy compared with the TARGET group at the 4-month follow-up.

Depression
There were also no significant differences between the groups on measures of depression.

Anxiety
There were significant improvements on measures of anxiety for the TARGET group compared with the ETAU comparison group at the 4-month follow-up.

Anger
The ETAU comparison group showed better improvements on measures of anger compared with the TARGET group at the 4-month follow-up.
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Evaluation Methodology

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Study 1
Ford and colleagues (2008) used a randomized control trial to study the effect of Trauma Affect Regulation: Guide for Education and Therapy (TARGET) on posttraumatic stress disorder (PTSD) symptoms and on stress management. A group of 147 low-income, multiethnic mothers, ages 18 to 45, were drawn from the Hartford, Conn., area and randomly assigned to one of three groups: waitlist treatment as usual (TAU, n=45); Present Centered Therapy (PCT, n=53); or TARGET (n=49). Exclusion criteria included substantial cognitive impairment, being on suicide watch, and being younger than 18. Inclusion criteria included parenting a child younger than 5 and a current diagnosis of partial or full PTSD.

Participants in the study were 39 percent European American, 33 percent African/Caribbean American, and 28 percent Latina or mixed race. Most participants lived alone; 30 percent had not completed high school, 27 percent were high school graduates, 21 percent had attended some college, and 22 percent were college graduates. Seventy-two percent had a comorbid anxiety or affective disorder with PTSD. Participants showed extensive exposure to psychological trauma; all demonstrated either full or partial PTSD. All participants in the study were female.

PCT provides psychoeducation about the link between trauma experience and PTSD, and focuses on the development of social problem-solving to enhance relationships. Individuals in the PCT received 12 sessions of supportive therapy. TARGET participants received individual counseling in 12 weekly sessions. The TAU individuals received no treatment.

Instruments used to assess measures of interest included the Traumatic Events Screening Inventory; the Clinician Administered PTSD Scale; the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV–TR); the Beck Depression Inventory; State–Trait Anxiety Inventory, State Version; the Posttraumatic Cognitions Inventory; the Interpretation of PTSD Symptoms Inventory; the Generalized Expectancies for Negative Mood Regulation; and Health-Related Functioning. Symptoms were assessed prior to treatment and at posttreatment; the treatment groups (but not the waitlist control group) were assessed again at 3- and 6-month follow-ups.

Therapy was delivered by eight female therapists with either doctoral degrees in clinical psychology or psychiatry or master’s degrees in social work, counseling, or marriage and family therapy. Therapists received 40 hours of training in TARGET and PCT.

Intent-to-treat analyses used mixed method regression. Covariates included age, marital status, education, ethnicity, and comorbid psychiatric disorders. Attrition was low in both treatment groups (between 6 percent and 10 percent).

Study 2
Ford and colleagues (2012) conducted a randomized controlled trial involving delinquent girls (ages 13–17) who met the following criteria: a) self-reported delinquency (based on national Delinquency Study criteria) and b) full or partial posttraumatic stress disorder (based on the Clinician-Administered PTSD Scale for Children/Adolescent [CAPS–CA] structured diagnostic interview). Study participants were recruited from November 2006 to April 2008 in Hartford, Conn., from school, health clinics, protective services offices, and residential treatment centers.

The 59 delinquent girls were randomized to either the treatment group, which received TARGET (n=33) or to Enhanced Treatment as Usual (ETAU) (n=26). The ETAU was designed to provide relational support in dealing with current life problems. The female study participants were 59 percent Latina or mixed race, 25 percent white (European American), and 16 percent black (African/Caribbean American). More than one third (37.5 percent) of the study group were in Department of Children and Families guardianship, and that same percentage had prior arrests for violent crimes. There were no significant differences between the groups on demographic or outcome measures, except on one measure: TARGET participants had greater symptoms of PTSD according to Criterion B on CAPS–CA, compared with ETAU group participants.

The primary outcome of interest was diagnoses for PTSD and partial PTSD using the CAPS–CA, which is a structured interview that assesses DSM–IV–TR categorical diagnoses for PTSD. The items assessed the intensity (from none to extreme distress) and frequency (from never to daily or almost every day) of each PTSD symptom. Ordinal symptom severity scores were calculated for PTSD overall and for Criteria B (intrusive reexperiencing), Criteria C (avoidance and emotional numbing), and Criteria D (hyperarousal) from the CAPS–CA. In addition, the Generalized Expectancies for Negative Mood Regulation Scale, a 30-item scale, was used to measure self-perceived ability to identify, manage, and utilize adaptively a variety of negative emotion states using a 1-5 scale (from strongly agree to strongly disagree). Subscales from the Trauma Symptom Checklist for Children, a 54-item questionnaire, were used to measure anxiety, depression, and anger. The items were rated from 0 (never) to 3 (almost all the time). The Posttraumatic Cognitions Inventory, a 36-item questionnaire, measured self-reported measures of posttraumatic beliefs related to the world, self, and self-blame. Finally, the Hope Scale, a six-item questionnaire, assessed dispositional hope (self-efficacy and optimism).

The baseline assessment interviews were conducted 14 to 21 days before the girls began treatment. A posttest interview was conducted about 4 months after the baseline interview. To examine the collected data, intent-to-treat analyses were done with all participants regardless of missing data, using mixed-modal regression.
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Cost

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There is no cost information available for this program.
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Evidence-Base (Studies Reviewed)

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These sources were used in the development of the program profile:

Study 1
Ford, Julian D., Karen L. Steinberg, Kathie Halback Moffitt, and Wanli Zhang. 2008. Breaking the Cycle of Trauma and Criminal Justice Involvement: The Mothers Overcoming and Managing Stress (MOMS) Study. Final Report to the U.S. Department of Justice. Farmington, Conn.: University of Connecticut Health Center.
http://www.ncjrs.gov/pdffiles1/nij/grants/222910.pdf

Study 2
Ford, Julian D., Karen L. Steinberg, Josephine M. Hawke, Joan Levine, and Wanli Zhang. 2012. “Randomized Trial Comparison of Emotion Regulation and Relational Psychotherapies for PTSD With Girls Involved in Delinquency.” Journal of Clinical Child & Adolescent Psychology 41(1):27–37.
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Additional References

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These sources were used in the development of the program profile:

Ford, Julian D., and Eileen Russo. 2006. “Trauma-Focused, Present-Centered, Emotional Self-Regulation Approach to Integrated Treatment for Posttraumatic Stress and Addiction: Trauma Adaptive Recovery Group Education and Therapy (TARGET).” American Journal of Psychotherapy 60(4): 335–55.

Ford, Julian D., Karen L. Steinberg, Josephine Hawke, Joan Levine, and Wanli Zhang. 2012. “Randomized Trial Comparison of Emotion Regulation and Relational Psychotherapies for PTSD with Girls Involved in Delinquency.” Journal of Clinical Child and Adolescent Psychology 41(1):27–37.

Ford, Julian D. Karen L. Steinberg, and Wanli Zhang. 2011. “A Randomized Clinical Trial Comparing Affect Regulation and Social Problem-Solving Psychotherapies for Mother With Victimization-Related PTSD.” Behavior Therapy 42(4):560–78.

Ford, Julian D. and Josephine Hawke. 2012. “Trauma Affect Regulation Psychoeducation Group and Milieu Intervention Outcomes in Juvenile Detention Facilities.” Journal of Aggression, Maltreatment & Trauma 21(4):365–84. (This study was reviewed but did not meet CrimeSolutions.gov criteria for inclusion in the overall program rating.)

Frisman, Linda K., Julian D. Ford, Hsiu–Ju Lin, Sharon Mallon, and Rocio Chang. 2008. “Outcomes of Trauma Treatment Using the TARGET Model.” Journal of Groups in Addiction and Recovery 3:285–303.

Knudsen, Kraig. 2008. “TARGET Evaluation.” Columbus, Ohio: Ohio Department of Mental Health, Office of Program Evaluation and Research. (This study was reviewed but did not meet CrimeSolutions.gov criteria for inclusion in the overall program rating.)
http://mha.ohio.gov/Portals/0/assets/Funding/research-evaluation/tsig-evaluation/target-program-evaluation.pdf

Marrow, Monique T., Kraig Knudsen, Erna Olafson, and Sarah E. Bucher. 2012. “The Value of Implementing TARGET Within a Trauma-Informed Juvenile Justice Setting.” Journal of Child and Adolescent Trauma 5:257–70.
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Related Practices

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Following are CrimeSolutions.gov-rated practices that are related to this program:

Psychotherapies for Victims of Sexual Assault
This practice examines interventions for adult sexual assault victims that reduce psychological distress, symptoms of post-traumatic stress disorder (PTSD), and rape trauma through counseling, structured or unstructured interaction, training programs, or predetermined treatment plans. The practice is rated Effective in reducing symptoms of trauma and PTSD in victims of sexual assault and rape.

Evidence Ratings for Outcomes:
Effective - More than one Meta-Analysis Mental Health & Behavioral Health - Trauma/PTSD
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Program Snapshot

Age: 13 - 45

Gender: Female

Race/Ethnicity: Black, Hispanic, White, Other

Geography: Urban

Setting (Delivery): Inpatient/Outpatient, Residential (group home, shelter care, nonsecure)

Program Type: Alcohol and Drug Therapy/Treatment, Group Therapy, Individual Therapy, Residential Treatment Center, Victim Programs, Children Exposed to Violence

Targeted Population: Females, Victims of Crime, Alcohol and Other Drug (AOD) Offenders

Current Program Status: Active

Listed by Other Directories: Child Exposure to Violence Evidence Based Guide, Model Programs Guide

Program Developer:
Julian Ford
Professor of Psychiatry, Graduate School Faculty
University of Connecticut Health Center
263 Farmington Avenue
Farmington CT 06030
Phone: 860.679.8778
Fax: 860.679.4326
Email

Researcher:
Julian Ford
Professor of Psychiatry, Graduate School Faculty
University of Connecticut Health Center
263 Farmington Avenue
Farmington CT 06030
Phone: 860.679.8778
Fax: 860.679.4326
Email

Training and TA Provider:
Judith Ford
President
Advanced Trauma Solutions, Inc
17 Talcott Notch Road
Farmington CT 06032
Phone: 860.269.8663
Fax: 860.606.0008
Website
Email