Duke University Department of Veterans Affairs

SMART: SUMMARY OF DUKE GUIDED IMAGERY STUDIES TO DATE


Jennifer Strauss PhD and her team at Duke Medical Center & the Durham V.A.M.C. have conducted one survey and 3 studies assessing SMART (Self-Management Audio for Recovery from Trauma) on soldiers and veterans with posttraumatic stress. The results have exceeded expectations, and compare with more expensive, time-consuming, and hard-to-implement best practices currently in use for PTSD. The data are now being analyzed and refined for pending journal articles and a larger grant is being submitted. Citations appear below.

  1. The 1st study was a survey of VA clinic users, showing that over 70% of active military & veterans prefer their help for stress through audio downloads. (Similar findings exist @ the Phoenix V.A. with Dr. Dana Epstein's survey on TBI-related sleep disorders.)

  2. The 2nd study was a small pilot (no controls) that looked at imagery's impact on 15 women with PTSD from Military Sexual Trauma, mostly from the Vietnam era, to see if it worked, if subjects liked it and would stay with it. They listened 5x/wk for 12 weeks. There were large, significant effect sizes - steep drops in symptoms, as measured by 2 gold-standard measures: the CAPS (Clinician Administered PTSD Scale) and the PCL (PTSD Checklist) - attaining scores comparable to individual therapy and to CBT/prolonged exposure therapy.

  3. The 3rd study was a recently completed randomized controlled trial funded by the Dept. of Defense through the Samueli Institute, then through an NIH grant, with 52 women suffering from MST, half in each group (the intervention group received SMART; while the controls rec'd the music alone). The population was mostly older, but 25% were OIF/OEF. This study yielded the same results: large, significant effect sizes, consistent with best outcomes from individuals with prolonged exposure. From this study, we found that 80% of change occurred by week #6. And though the music controls also showed impressive improvement, the guided imagery group still maintained treatment gains at week #36, whereas the controls were trending back towards their baseline levels by then.

  4. The 4th pilot study was an open trial with 20 male vets with combat-related PTSD. The intervention was framed as "skills training", as opposed to "therapy"; the program was shortened to 8 weeks; and changes were made to the audio content, based on previous feedback, allowing subjects to choose from any of 5 possible tracks, as long as they listened for a minimum of a half hour a day, 5 days a week. In this group, there was unusually high retention (85%), positive feedback and even larger effect sizes on all PTS clusters, at least comparable to results from individual exposure therapy with a therapist for 8-12 weeks.*

Implications:
Although larger numbers are needed to validate these data, they are nonetheless highly promising, compelling & consistent. It is likely that SMART can reduce mild or moderate PTS symptoms on its own; or may be a useful adjunct to prolonged exposure therapy, to help minimize the distress this protocol can generate; and it may even be helpful in inoculating against the later acquisition of PTS symptoms or reducing their severity, by being part of early training. Highly practical, it is cost-effective, self-administered, user-friendly, non-threatening and portable.

* At baseline, the average CAPS score was 88.65 (19.83) as compared to 55.38 (26.97) at posttreatment, translating into a pre-post effect size of d = 1.45. Effect sizes for the three PTSD symptom clusters are as follows: for Cluster B (intrusive, re-experiencing symptoms), d =1.10; for Cluster C (avoidance & numbing symptoms), d = 1.47; and for Cluster D (hyper-arousal and reactivity symptoms), d = 1.07. For the PCL, average baseline = 65.50 (10.60) versus 54.13 (17.85) at posttreatment; Cohen's d = 0.82.]


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