Facing Posttraumatic Stress Disorder in Brazil: A Survey of Therapist Practices

doi:10.21203/rs.3.rs-1419658/v1

Background

Brazil is a large, diverse, and heterogeneous country, and to date few studies have delved into the prevalence of PTSD within its population, or into how it has been treated. The aim of the present study was to report and discuss the results of a survey addressing the professional approaches adopted by Brazilian clinicians in treating PTSD.

Methods

Exploratory cross-sectional study targeted at therapists that had treated at least one PTSD case throughout their career. The data were collected from February 27th to May 8th, 2020, from a convenience sample (n = 208) of psychologists and physicians using an online form. The main subject matters were the psychotherapeutic treatments; diagnostic procedures; screening and assessment techniques; and difficulties and challenges.

Results

Less than half of the total sample (48.1%) declared they used instruments for screening and diagnosing. Cognitive behavioral therapy (CBT) was the most adhered to theoretical model (49%), more than 20 theoretical affiliations were mentioned, and 86 clinicians (41.3%) disclosed adherence to more than one theory, denoting an eclectic group. The individual case analysis, the scientific evidence, and treatment acceptance were ranked the most relevant criteria when selecting treatment. The most empirically supported trauma-focused psychotherapies were not among the more widely used. Lack of PTSD content in undergraduate courses (38.5%) was considered an important barrier to effective treatment.

Conclusions

The results may help mental health policymakers and providers devise strategies to bridge the gap between research and actual service delivery. The apparent short supply of training and supervision on evidence-based therapies poses an opportunity for colleges and other educational centers.

PTSD

treatment

evidence-based

trauma-focused psychotherapy

training

Brazil

Several treatments for posttraumatic stress disorder (PTSD) have been advanced throughout the years, but only a handful has made it as strongly recommended by the main clinical practice guidelines available (1). Hamblen et al. (1) reviewed those guidelines and provided a handy summary of their methodological underpinnings, classification criteria, and recommendations. In short, all or most of them strongly recommend a few so-called trauma-focused psychotherapies (TFTs) (2), namely prolonged exposure (PE), cognitive processing therapy (CPT), trauma-focused cognitive behavioral therapy (TF-CBT), and eye movement desensitization and reprocessing (EMDR), whereas recommendation for options like brief eclectic psychotherapy, written narrative exposure or narrative exposure therapy was also strong, but in only some of the guidelines.

Given a certain level of exposure to potentially traumatic events (PTE), the probability of developing PTSD may vary across cultural and socioeconomic groups, as well as through the lifespan [3, 4]. It has been indicated that there is a high and significant association between frequent exposure to violence and mental health problems in low and middle-income countries, and PTSD was found to be associated with sexual and domestic violence, kidnapping, and cumulative trauma exposure within the general population in Brazil [4, 5], which is a country that struggles with chronic violence issues [6, 7]. Also, it seems plausible that this situation may have worsened due to the Covid-19 pandemic [8–10].

Brazil is a diverse and heterogeneous country and to date, few studies have delved into the prevalence of PTSD within its population, no one nationwide. A noteworthy case in point is Ribeiro et al. [11], who conducted a cross-sectional survey with a probabilistic sample of 15- to 75-year-old residents of São Paulo and Rio de Janeiro (Rio), using the Portuguese language version of the Composite International Diagnostic Interview (CIDI 2.1). Its aim was to study the relationship between traumatic events and the prevalence of mental disorders in general.

The study results revealed that in the country’s two largest cities, with respectively 12.39 million and 6.77 million inhabitants [12], PTSD lifetime prevalence was 10.2% (14.7% for females) and 12-month prevalence was 5% (females 7.8%) in São Paulo, whereas in Rio the figures were 8.7% lifetime prevalence (females 11.1%) and 3.3% 12-month prevalence (females 4.7%). Conversely, it was shown that PTE exposure had an 86.0% lifetime prevalence in São Paulo and 88.7% in Rio and that 12-month prevalence was 21.7% and 35.1%, respectively. Besides, it is worth noting that a minority among those participants who were exposed to a PTE reported experiencing just one type of traumatic event through their lifespan, adding up to 26% in São Paulo and 20% in Rio [11].

According to the DSM-5 [13], PTSD is classified as a trauma- and stressor-related disorder, which means that exposure to stressful or traumatic events is a diagnostic criterion. More precisely, a positive diagnosis requires exposure to actual or threatened death, serious injury, or sexual violence, either through direct experience, by witnessing the event, or even learning about the actual or threatened death of a family member or friend. Besides that, repeated or extreme exposure to aversive details of traumatic events in professional contexts (such as by firefighters or medical professionals) is also a possibility. Other criteria include symptoms clustered around the presence of at least one intrusion; avoidant behaviors related to distressing memories, thoughts, and feelings; negative mood; and also an arousal dimension. Altogether, the disturbances should last more than one month, impair the person’s normal functioning, and not be caused by a substance intake [13].

The aim of the present study is to report and discuss the results of a survey to address the professional approaches adopted by Brazilian clinicians in treating PTSD. There is a dearth of information regarding this issue and it is expected that the endeavor will help guide the practitioners themselves in reflecting upon their chosen practices, as well as give important clues to both the academic community and educational institutions, which can possibly benefit from new research hypotheses and potentially improve their curricula so as to provide evidence-based training to their students.

This was an exploratory cross-sectional study. To the best of our knowledge, no previous countrywide research has tackled the issue of how Brazilian clinicians treat posttraumatic stress disorder. The size of the target population was not known. It was defined as comprising the therapists that have treated at least one PTSD case throughout their career. No such database was available, either through the national or the regional associations representing the Brazilian psychology professionals. Thus, it was not possible to employ a probabilistic sampling method. Instead, convenience sampling was used, which yielded an n = 208 sample.

Ethics Statement

The study participants were informed about its purpose, content, and likely time to questionnaire completion, and asked to freely consent to participate. They did not have to answer all the questions and could quit participating whenever they wished. Besides, the data collected could not lead to respondent identification. Brazilian regulations [14] do not require an anonymous survey answered by mental health professionals to be approved by an ethics committee.

Participants

Participants were chosen by convenience from the following sources: (i) authors of papers about PTSD indexed in the Scielo database (n = 106); (ii) members of mobile-app groups of psychologists (n = 299); and (iii) the list of psychologists authorized by the Federal Police to assess applicants for gun possession (n = 2,443). Each therapist received a personal message which briefly stated the research purpose, presented the researchers and their institutional affiliations, and disclosed how the person’s contact was obtained. An invitation to participate and a link to an online questionnaire went along.

As soon as the participant opened the link, basic filling instructions were given, together with the respondent’s anonymity assurance, contact information, and an estimate about the time required to complete the form. Before proceeding to the first question, he or she had to formally consent to the participation terms, and confirm having engaged in the treatment of at least one PTSD case.

The data were collected from February 27th to May 8th, 2020, and there were 208 eligible responses, 194 from psychologists (93.3%), and 14 from physicians (6.7%; 13 psychiatrists and one family physician). The sample comprised therapists from all but three of the 27 federal states ––Acre, Amazonas, and Roraima–– in the North Region. Accordingly, the country’s five big geographic regions were unevenly represented. The North, with an 8.8% share of the Brazilian population [for all population figures, 12], counted 2.4% of the sample, whereas the Northeast, which accounts for 27.0% of the population, contributed 12.5% of the respondents, and the Southeast, where 42.0% of the nation’s inhabitants are, added 29.8% of the responses. Conversely, the population and sample shares were, respectively, 7.8% and 28.8% for the Center-West, and 14.3% and 26.4% for the South Region.

Instrument

The research instrument [Supplementary Information 1-3], written in the Portuguese language, was developed from scratch because no suitable equivalent was available. The online questionnaire had twenty questions that aimed to identify the professional approaches adopted by Brazilian clinicians in treating PTSD. Part of the multiple-choice questions had a fixed set of possible answers, whereas some had an option that allowed respondents to add an alternative answer. Additionally, there were checkbox questions, for which more than one alternative could be selected. It was divided into five sections: (i) personal data; (ii) information about the psychotherapeutic treatments; (iii) diagnostic and screening procedures; (iv) PTSD scales, tests, and assessment techniques; and (v) difficulties and challenges faced in PTSD treatment.

Data Analysis

Descriptive statistics analysis included frequency, percentage, mean and standard deviation. The association between the variables was tested using Cramér's V coefficient, which provides the strength of association between categorical variables in a contingency table. Its values range from 0 (no relation) to 1 (perfect association). Generally, values up to 0.29 indicate a negligible or weak association, and values between 0.30 and 0.49 point to a moderate correlation [15].

A total of 2.848 professionals were contacted and 273 (9.6%) returned the survey. From these, 12 did not agree to the participation terms and 65 had never treated PTSD patients, being thus excluded from the survey. The results are presented for the full sample (n = 208) as well as for the two sample groups: psychologists (n = 194) and physicians (n = 14). The average time since graduation for all participants was 16.76 years (SD = 10.19) and a significant difference was observed between psychologists (M = 16.03, SD = 9.72) and physicians (M = 27.00, SD = 11.48), t(206) = 4.0312, p < 0.0001, d = 10.97, 95% CI [5.61, 16.34].

Table 1 shows the main sample characteristics regarding gender, education level, years of practice, clientele assisted, working field, and number of PTSD patients treated. Altogether, most therapists were women (79.3%), reflecting the higher prevalence of females among psychologists (83%), but not among physicians (28.6%). The majority of participants (60.6%) held a specialist degree and no more than 24.5% had a master’s (14.4%) or doctor’s (10.1%) education level, although it should be noted that the proportion of doctors among physicians was 42.9%. This may express the fact that the group from the medical profession was a more seasoned one, as 64.3% of them had 20 years or more of practice, whereas psychologists with comparable experience were 21.7%. The full sample’s clientele consisted mostly of adults, which were assisted by 94.2% of the participants. A high share of adolescents was treated by psychologists (61.9%) but not so much by physicians (35.7%). Clinical psychologists were 72.2% among these professionals, with smaller proportions coming from fields like health (8.8%) and work (4.1%) psychology or psychological assessment (4.1%). All but one physician were psychiatrists or 92.9% of this sample.

Table 1 Sample characteristics

	Psychologists		Physicians		Full sample
	n	%	n	%	n	%
Gender
Female	161	83.0	4	28.6	165	79.3
Male	33	17.0	10	71.4	43	20.7
Non-binary	0	—	0	—	0	—
Education Level
Graduate	30	15.5	1	7.1	31	14.9
Specialist degree ^a	121	62.4	5	35.7	126	60.6
Master	28	14.4	2	14.3	30	14.4
Doctoral	15	7.7	6	42.9	21	10.1
Years of practice
< 1	5	2.6	0	—	5	2.4
1 – 5	32	16.5	0	—	32	15.4
6 – 10	52	26.8	1	7.1	53	25.5
11 – 15	32	16.5	4	28.6	36	17.3
16 – 20	31	16.0	0	—	31	14.9
> 20	42	21.7	9	64.3	51	24.5
Clientele assisted ^b
Adults	182	93.8	14	100.0	196	94.2
Adolescents	120	61.9	5	35.7	125	60.1
Children	69	35.6	2	14.3	71	34.1
Elderly	47	24.2	6	42.9	53	25.5
Couples	42	21.6	0	—	42	20.2
Groups	39	20.1	1	7.1	40	19.2
Families	38	19.6	1	7.1	39	18.8
Other ^c	16	8.2	0	—	16	7.7
Working field
Clinical psychology	140	72.2	0	—	140	67.3
Health psychology	17	8.8	0	—	17	8.2
Work psychology	8	4.1	0	—	8	3.8
Psychological assessment	8	4.1	0	—	8	3.8
Social psychology	6	3.1	0	—	6	2.9
Psychiatry	1	0.5	13	92.9	14	6.7
General Practitioner	-	-	1	7.1	1	0.5
Other ^d	14	7.2	0	—	14	6.7

Note. Percentages may not add up to 100.0 due to rounding.

^a According to Brazilian regulations, a postgraduate degree contingent on the conclusion of a 360-hour specialization course, not equivalent to a master or doctoral degree [16].

^b More than one alternative could be selected. Percentages of participants that chose each.

^c Psychological assessment, support in a hospital environment, labor health.

^d School psychology, traffic psychology, neuropsychology, legal psychology.

In Table 2 the therapists’ experience, treatment context, and therapeutic approaches to PTSD are depicted. Regarding the respondents’ experience in treating PTSD patients, the profile was mixed: 25.9% of psychologists had treated up to five patients, 22.3% between six and 10, and 34.2% more than 20 people with this diagnosis. On the other hand, physicians were noticeably more experienced, because 92.9% of them had treated more than 20 PTSD patients.

About the traumatic events associated with PTSD in Brazil, in line with previous literature [5], the most commonly reported events were related to some of the country’s major violence issues, such as childhood sexual abuse (78.8%), mugging (60.1%), physical violence in childhood (50%), sexual abuse in adulthood (45.6%), knowledge of death or physical harm to someone close (43.8%), and experiencing physical violence as an adult (41.8%). On the other hand, the traumatic events related to physical health issues, like severe medical conditions (36.1%) and severe hospital context (32.7%), although still relatively important, were less prevalent. Overall, the list of traumatic events associated with PTSD was fairly extensive, with 13 of them reported by at least 25% of the clinicians.

Regarding the work settings in which the PTSD treatment has been performed, private offices were the most frequent environment (87.5%), followed by public health system premises (24.5%), and private hospitals (15.4%). This study also examined which theoretical models were mostly referenced by therapists who treated PTSD in Brazil. The results showed that cognitive behavioral therapy (49%), psychoanalytic therapy (26%), behavior analysis (23.6%), and person-centered therapy (19.2%) were the most cited in this regard. More than 20 approaches were mentioned, and 86 clinicians, or 41.3% of the full sample, disclosed adherence to more than one theory.

Table 2 Experience, treatment context, and therapeutic approaches to PTSD

	Psychologists		Physicians		Full sample
	n	%	n	%	n	%
PTSD patients treated ^a
1 – 5	50	25.9	0	—	50	24.2
6 – 10	43	22.3	0	—	43	20.8
11 – 15	22	11.4	0	—	22	10.6
16 – 20	12	6.2	1	7.1	13	6.3
> 20	66	34.2	13	92.9	79	38.2
Most frequent traumatic events ^b
Childhood sexual abuse/violence	151	77.8	13	92.8	164	78.8
Mugging	112	57.7	13	92.8	125	60.1
Physical violence in childhood	94	48.5	10	71.4	104	50.0
Sexual abuse/violence in adulthood	83	42.8	12	85.7	95	45.7
Know of death or physical harm to someone close	81	41.7	10	71.4	91	43.8
Physical violence as adult	74	38.1	13	92.8	87	41.8
Car, plane, or boat accident	75	38.7	11	78.6	86	41.3
Witness death or physical harm	71	36.6	12	85.7	83	39.9
Severe medical condition	68	35	7	50	75	36.1
Severe hospital context	61	31.4	7	50	68	32.7
Accident in a work environment	49	25.3	10	71.4	59	28.4
Mutilation	48	24.7	4	28.6	52	25.0
Contact with death or physical harm at work	45	23.2	7	50	52	25.0
Other ^c	140	72.1	0	—	140	67.3
Work setting ^b
Private office	168	86.6	14	100	182	87.5
Public health system	41	21.1	10	71.4	51	24.5
Private health system (hospital)	29	14.9	3	21.4	32	15.4
Teaching hospital	17	8.7	5	35.7	22	10.6
Police facility	15	7.7	3	21.4	18	8.7
Non-governmental organization	9	4.6	0	—	9	4.3
Armed forces	5	2.6	0	—	5	2.4
Other ^d	19	9.8	0	—	19	9.1
Theoretical models ^b
Cognitive behavioral therapy	91	46.9	11	78.6	102	49.0
Psychoanalytic therapy	52	26.8	2	14.3	54	26.0
Behavior analysis	48	24.7	1	7.1	49	23.6
Person-centered therapy	36	18.5	4	28.6	40	19.2
Gestalt therapy	19	9.8	0	—	19	9.1
Body therapies	14	7.2	0	—	14	6.7
Psychodrama	13	6.7	0	—	13	6.3
Jungian analysis	12	6.2	0	—	12	5.8
EMDR	8	4.1	1	7.1	9	4.3
Systemic therapy	5	2.6	0	—	5	2.4
Somatic Experiencing	5	2.6	0	—	5	2.4
Ericksonian psychotherapy	4	2.0	0	—	4	1.9
Other ^e	14	7.2	0	—	14	6.7

Note. Percentages may not add up to 100.0 due to rounding.

^a One missing answer for psychologists (n = 193; n = 207 for full sample).

^b More than one alternative could be selected. Percentages of participants that chose each.

^c Kidnapping, natural disasters, industrial accidents, kidnapping with sexual violence, war, and so forth.

^d Fire department, civil defense, online, judiciary, and so forth.

^e Acceptance and commitment therapy, health psychology, psychosensory therapy, interpersonal therapy, Sartre’s existentialism, and so forth.

Other research aims were to reveal how PTSD assessments were performed, the diagnostic and screening tools used, and the treatment procedures employed by Brazilian clinicians. These results are shown in Table 3. Concerning this matter, it is worth underlining that about half of the psychologists (107; 55.2%) and all the physicians (14) affirmed that they themselves performed diagnoses. Interestingly, 94 psychologists (48.5%) and 6 physicians (42.9%) indicated using assessment instruments for this purpose. Among those who did affirm using instruments to diagnose or screen for PTSD, the Structured Clinical Interview for DSM-5 Disorders (SCID-5-CV) (33.2%) and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) (25.0%) were the most preferred means, followed by the self-reported Screen for Posttraumatic Stress Symptoms (SPTSS) (14.9%) and PTSD Checklist for DSM-5 (PCL-5) (8.7%).

Regarding the procedures used in PTSD treatment by Brazilian clinicians, the most common were relaxation techniques (56.3%), cognitive restructuring (45.7%), affect management (38.5%), and mindfulness (30.8%). Apart from that, prescribing medication was the main procedure mentioned by physicians (92.9%), as would have been expected, given that only medical professionals are granted prescribing privileges in Brazil. Given this limitation, it was odd that 21 psychologists (10.8%) also declared using medicines in therapy. Besides, many did not feel obliged to any standardized procedure (14.9%), and well researched and supported procedures like PE (14.4%) and EMDR (12.5%) were not among the most favored in the therapists’ toolkit.

Table 3 Diagnoses, instruments, and procedures used in PTSD treatment

	Psychologists		Physicians		Full sample
	n	%	n	%	n	%
The diagnosis was performed by
The professionals themselves	107	55.2	14	100	121	58.2
Another psychiatric doctor	67	34.5	0	—	67	32.2
Another psychologist	7	3.6	0	—	7	3.4
Other^a	13	6.7	0	—	13	6.3
Diagnosis and screening instruments^{b, c}
Structured Clinical Interview for DSM-5 Disorders (SCID-5-CV)	64	33.0	5	35.7	69	33.2
Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)	48	24.7	4	28.6	52	25.0
Screen for Posttraumatic Stress Symptoms (SPTSS)	31	16.0	0	—	31	14.9
PTSD Checklist for DSM-5 (PCL-5)	14	7.2	4	28.6	18	8.7
Impact of Event Scale – Revised (IES-R)	13	6.7	4	28.6	17	8.2
Life Events Checklist for DSM-5 (LEC-5)	14	7.2	3	21.4	17	8.2
PTSD Checklist – Civilian Version (PCL-C)	9	4.6	4	28.6	13	6.3
Impactful Occupational Stressors Survey	13	6.7	0	—	13	6.3
Davidson’s Trauma Scale (DTS)	8	4.1	1	7.1	9	4.3
Other ^d	12	6.2	0	—	12	5.8
Procedures ^c
Relaxation techniques	110	56.7	7	50.0	117	56.3
Cognitive restructuring	88	45.4	7	50.0	95	45.7
Affect management	77	39.7	3	21.4	80	38.5
Mindfulness	59	30.4	5	35.7	64	30.8
Medication	21	10.8	13	92.9	34	16.3
No standardized procedure	30	15.5	1	7.1	31	14.9
Prolonged exposure (PE)	30	15.5	0	—	30	14.4
Eye Movement Desensitization and Reprocessing (EMDR)	24	12.4	2	14.3	26	12.5
Biofeedback	23	11.9	0	—	23	12.0
Auxiliary alternative procedures ^e	22	11.3	2	14.3	24	11.1
Hypnotherapy	21	10.8	0	—	21	10.1
Psychodynamic procedures	10	5.2	2	14.3	12	5.8
Other ^f	27	13.9	0	—	27	13.0

Note. Percentages may not add up to 100.0 due to rounding.

^a Both a psychologist and a psychiatrist; a general practitioner; a multi-professional team; and so forth.

^b Of the 208 survey participants, 94 psychologists (n = 94) and six physicians (n = 6) affirmed to use diagnostic and screening instruments (n = 100, full sample).

^cMore than one alternative could be selected. Percentages of participants that chose each.

^d Mini-International Neuropsychiatric Interview (M.I.N.I.), International Trauma Questionnaire (ITQ), Dissociative Experiences Scale (DES-II), Rorschach, and so forth.

^e Yoga, acupuncture, reiki, meditation, and so forth.

^f Brainspotting, systematic desensitization, somatic experiencing, and so forth.

Furthermore, when asked to rank (on a 5-point scale, from first [coded 1] to fifth [5], based on its relevance) the criteria used to choose which treatment procedures they use, the results showed a preference for the analysis of each case (M = 2.28, SD = 1.40) followed by the choice of procedures based on scientific evidence (M = 2.65, SD = 1.39) as decision criteria. On the other hand, the patient’s treatment acceptance (M = 3.26, SD = 1.25), the alignment of the procedure with the therapist’s theoretical approach (M = 3.32, SD = 1.32), and the procedure’s effectiveness as informed by the clinician’s experience (M = 3.49, SD = 1.34) were indicated as less relevant.

In regard to the difficulties and challenges faced when treating PTSD, as shown in Table 4, the main troubles encountered by therapists stemmed from patient-related factors, such as their resistance to talk about the traumatic event (48,1%), dropout (46.6%), and low motivation (30.8%), though one particular therapist-related factor —lack of PTSD content in undergraduate courses (38.5%)—, also standed out as relevant. When it comes to the professional training that would be needed to improve delivered treatment, emphasis was put on specialized courses (63.5%), supervision (63.0%), and specific training during undergraduate studies (59.1%).

Table 4 Difficulties in dealing with PTSD patients and training needs

	Psychologists		Physicians		Full sample
	n	%	n	%	n	%
Main difficulties with PTSD patients ^a
Patient's resistance to talk about the traumatic event	95	49.0	5	35.7	100	48.1
Patient quits before the end of treatment	92	47.4	5	35.7	97	46.6
Absent or scarce PTSD content in undergraduate courses	75	38.7	5	35.7	80	38.5
Patient's low motivation to engage in treatment	60	30.9	4	28.6	64	30.8
Patient's relapse after treatment	33	17.0	4	28.6	37	17.8
Lack of training opportunities for the therapist	26	13.4	2	14.3	28	13.5
Therapist’s lack of familiarity with PTSD	21	10.8	0	—	21	10.1
Patient's improvement is too slow or can't be noticed at all	11	5.7	3	21.4	14	6.7
Other^b	28	14.4	4	28.6	32	15.4
Training needed for satisfactory PTSD treatment ^a
Completion of specialized courses about PTSD	123	63.4	5	35.7	132	63.5
Supervision	122	62.9	5	35.7	131	63.0
Specific training during undergraduate studies	116	59.8	5	35.7	123	59.1
More publicity to treatment options	98	50.5	4	28.6	104	50.0
More dissemination of scientific literature	96	49.5	4	28.6	104	50.0
Availability of treatment manuals	78	40.2	2	14.3	84	40.4
Other ^c	10	40.2	0	—	10	4.8

^a More than one alternative could be selected. Percentages of participants that chose each.

^b Therapist’s low motivation, patient’s socioeconomic situation, therapist’s own emotions, and so forth.

^c Books with case studies, courses on PTSD related topics, and so forth.

To examine the relationship between the relevant variables, a correlation analysis using Cramér’s V coefficient was performed. The results showed a very weak to negligible correlation between practice time and procedures adopted; between the education level and the procedures; and also between the theoretical approach and the procedures [15, Supplementary Information 4].

The aim of the present survey was to report and briefly discuss the professional approaches adopted by Brazilian clinicians in treating PTSD, providing what’s to our knowledge the first assessment of this kind conducted in the country. The questionnaire was answered during 10 weeks in early 2020, after Covid-19 was recognized as a pandemic by the World Health Organization [17]. Nevertheless, the most frequent traumatic events reported (see Table 2) didn’t seem to reflect at that point the infectious disease’s expected psychological consequences [8, 10], maybe due to the fact that there is a gap between the onset of symptoms and the search for help. They were rather more directly linked to Brazil’s chronic violence issues, in accordance with what the literature suggests [5, 6].

When it came down to screening and diagnosing, less than half of the total sample (48.1%) declared they used instruments for those purposes, which conveys a degree of diagnostic uncertainty. Anyhow, to this end, the Structured Clinical Interview for DSM-5 Disorders (SCID-5-CV) (33.2%) and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) (25.0%) were the preferred ones. Interestingly, although the International Classification of Diseases (ICD-11) [18] diagnostic criteria are the ones officially adopted by the Brazilian unified health system (Sistema Único de Saúde [SUS]), the countrywide public health system, only one participant reported having used the International Trauma Questionnaire (ITQ), which is a self-report measure of ICD-11 for PTSD and complex PTSD that has been translated and adapted for use in Brazilian Portuguese [19, 20].

The results showed that cognitive behavioral therapy (CBT) was the most adhered to theoretical model in the whole sample (49%), especially among physicians (78.6%). Secondly, psychoanalytic therapy (26%), behavior analysis (23.6%), person-centered therapy (19.2%), and Gestalt therapy (9.1%) figured as conceptually central for many therapists. More than 20 theoretical affiliations were mentioned, and 86 clinicians (41.3%) disclosed adherence to more than one theory, denoting an eclectic group. In fact, eclecticism is not uncommon in psychological practice around the world and could be more associated with therapists’ attitudes than with their training [21]. To be sure, blends of theoretical influences in the realm of clinical psychology in general and trauma therapy in particular, have also been detected, for instance, in the United States of America [22-24], Canada [25], and Poland [26].

Relaxation techniques (56.3%), cognitive restructuring (45.7%), affect management (38.5%), and mindfulness (30.8%) were the most cited procedures utilized by both physicians and psychologists. This result does not come as a surprise because all four practices are usually part of the CBT arsenal [27]. In turn, techniques like PE (14.4%) and EMDR (12.5%), which are highly recommended for the treatment of PTSD [1], were among the least favored in the therapists’ toolkit. This result resembles some of those reported by other researchers across different populations [23-25, 28].

To illustrate, Cook et al. [23] surveyed 2,200 North American psychotherapists about various aspects of their practice and found out that CBT was the leading theoretical orientation (79%). According to this study, family systems (49%), mindfulness (41%), psychodynamic (36%), and Rogerian/client-centered/humanistic (31%) therapies came ranked next. The practices most endorsed by the participants were largely related to the therapeutic alliance, such as trying to convey warmth and respect, communicating that the client is accepted and prized, communicating understanding, empathizing, and cultivating the therapeutic relationship, among others. Besides those, fewer also mentioned performing biofeedback, neurofeedback, body therapies, hypnotherapy, paradoxical techniques, EMDR, and so on.

Another survey, by Hipol and Deacon [24], examined the psychotherapeutic interventions used in the past 12 months for anxiety disorders (OCD, PTSD, panic disorder, and social phobia) treatment by community practitioners in rural Wyoming State, USA. In the case of PTSD, this study found that among the most used (above 70%) were cognitive restructuring, non-directive supportive therapy, mindfulness techniques, and arousal-reduction strategies, such as progressive muscle relaxation and breathing retraining. Around half mentioned client self-directed in vivo exposure, meditation, imaginal exposure, ACT, psychodynamic therapy, and motivational interviewing. Only a minority utilized therapist-assisted exposure (19.1%) and EMDR (17%).

Not surprisingly, because only medical professionals are granted prescribing privileges in Brazil, medication was the main procedure mentioned by physicians (92.9%) in our sample. Oddly though, it is not clear why 10.8% of psychologists also said they used medicines as a treatment procedure.

Implications for Practice and Education

As recommended by the APA Presidential Task Force on Evidence-Based Practice [29], three pillars should guide treatment selection, namely, the available scientific evidence, the clinician’s expertise, and the patient’s characteristics, culture, and preferences. In the present study, therapists were asked to rank five criteria they used for the selection of which treatment procedure they would employ when faced with a PTSD case. According to its average relevance, the following criteria were pointed, in descending order: (i) the individual case analysis, (ii) the scientific evidence, (iii) treatment acceptance, (iv) alignment with a theoretical approach, and (v) effectiveness as informed by the therapist’s experience. This result seems to indicate that Brazilian clinicians’ practices tend to be in line with those pillars.

However, although respondents rated the availability of scientific evidence as important when choosing interventions, the eight most empirically supported trauma-focused psychotherapies (PE, CPT, TF-CBT, EMDR, brief eclectic psychotherapy, written narrative exposure, and narrative exposure therapy) [1] were not among the more widely used. Granted, some procedures with a moderate to low level of recommendation according to clinical guidelines were also reported, like skills training in affect regulation, relaxation training, and psychodynamic psychotherapy. Taken together, these data suggest that individuals suffering from PTSD in Brazil may not be receiving the most effective treatments available.

That is rather unfortunate, because evidence-based practice provides a range of practical procedures to overcome the discontinuity between research and clinical intervention, improves the quality and cost-effectiveness of treatments, promotes effective psychological practice, and enhances public health [29, 30]. Therefore, even though it is important not to assume that interventions that have not yet been as studied are ineffective, the present low use of evidence-based practices for PTSD treatment in Brazil invites further investigation. Anyway, there is indication that this sub-utilization of the currently most effective treatments can be observed elsewhere in the world [23-25, 31, 32].

In the present study, patient-related factors, such as their resistance to talk about the traumatic event (48,1%), dropout (46.6%), and low motivation (30.8%), stood out as major difficulties and challenges faced when treating PTSD. However, it should be noted that these factors are probably also correlated with therapist characteristics, aspects of treatment delivery, and the therapeutic relationship [33, 34]. Another important barrier to effective treatment stemmed from a more unambiguously therapist-related factor: lack of PTSD content in undergraduate courses (38.5%). Indeed, when it came to the professional training that would be needed to improve treatment delivery, respondents emphasized specialized courses (63.5%), supervision (63.0%), and specific training during undergraduate studies (59.1%).

Importantly, a lack of training and supervision opportunities has been often cited in the literature as a major hindrance to the adoption of evidence-based psychological treatments for PTSD [31, 35-38]. To fill in the gap, some training protocols and programs have been proposed [31, 39, 40]. What the actual training is towards PTSD treatment provided by medical and psychology schools and universities in Brazil remains an empirical question, although our results clearly imply there is ample room for improvement.

Regarding public policy toward this matter, it is worth observing that only recently has a national public authority published an extensive guideline to PTSD treatment [41], which encourages prevention techniques such as psychological defusing and debriefing. Besides these, CBT in general is promoted through the endorsement of interventions like exposure, cognitive restructuring, biofeedback, and EMDR. The guidelines also recommend complementary practices, especially acupuncture, meditation, yoga, and reiki. Anyhow, no detailed protocols are provided.

Limitations and Future Directions

This research has its limitations. First, for some reasons, it was not possible to employ a probabilistic sampling method: the size of the target population was unknown, neither was data on therapists’ regional distribution, nor detailed information on sample representativeness. Therefore, convenience sampling was used, meaning that the findings cannot be readily generalized.

The sample (n = 208) was relatively small and comprised therapists from 24 out of the 27 federal states. The proportion in the sample that came from each of the country’s five big geographic regions did not match the respective population. A small sample size was more of an issue regarding the 14 physicians surveyed (6.7%). Nevertheless, our results seem to have captured differences in profile, procedures, and treatment approaches between psychologists and psychiatrists compatible with those already detected in the literature [42].

As a strength, the sample was geographically and demographically diverse, which is particularly relevant in a large country like Brazil. Conversely, another shortcoming was that ethnic and socioeconomic data were not collected.

A further limitation was that the declarative survey procedure itself may have resulted in a degree of bias. Firstly, because the questionnaire assessed the research topics via retrospective recall, without a time limit, which can be distorted by memory inaccuracy. Besides, it is not possible to rule out selection or social desirability biases from the voluntary and anonymous answers. That is, clinicians with a given profile may have been more motivated to participate or, for instance, may have declared greater use of scientifically validated interventions than they actually do [43].

This was the first survey to address the professional approaches adopted by Brazilian clinicians in treating PTSD. Future studies should address the aforementioned limitations.

The current cross-sectional study provides a first-hand picture of PTSD care in Brazil. Hopefully, it may help mental health policymakers and providers devise strategies to bridge the gap between research and actual service delivery, for the maximum benefit of the affected population. It is also apparent that there is a short supply of training and supervision focused on evidence-based therapies, which in turn poses an opportunity for colleges and other educational centers to tailor their courses to these demands.

Funding

The authors declare that no funds, grants, or other financial support were received during the preparation of this manuscript.

Competing Interests

Joana Singer Vermes is partner-director of the Centro Paradigma de Ciências do Comportamento. The other authors have no potential conflict of interest to disclose.

Author Contributions

MCC contributed to the study conception and design, material preparation, data collection and analysis, and wrote the first draft of the manuscript. LJS contributed to the study conception and design, and material preparation, data collection and analysis. JSV contributed to the study conception and design, data collection and analysis, and critically revised the research instrument and the final manuscript. CLMR contributed to the study conception and design, material preparation, data collection and analysis. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Ethics Approval

This is an anonymous observational study directed at health professionals for which Brazilian research regulations do not require approval by an ethics committee.

Consent to Participate

Written informed consent was obtained from all individual participants included in the study.

Consent to Publish

The manuscript contains no individual person’s data in any form.

Data Availability

The authors declare that the data supporting the findings of this study are available within the article and its supplementary information files.

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Facing Posttraumatic Stress Disorder in Brazil: A Survey of Therapist Practices

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions