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

This is a trauma-focused psychotherapy program for those suffering from posttraumatic stress disorder (PTSD). The program is rated Effective. Treated adults showed statistically significant lower PTSD symptoms, depression, and anxiety than comparison group adults. Treated youth showed statistically significant higher levels of hope and lower levels of the PTSD criterion of intrusive re-experiencing than comparison group youth, but there were no impacts in other mental health outcomes.

An Effective rating implies that implementing the program is likely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

This program's rating is based on evidence that includes either 1) one study conducted in multiple sites; or 2) two or three studies, each conducted at a different site. Learn about how we make the multisite determination.

An Effective rating implies that implementing the program is likely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

This program's rating is based on evidence that includes either 1) one study conducted in multiple sites; or 2) two or three studies, each conducted at a different site. Learn about how we make the multisite determination.

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

The following three main components of TARGET are delivered through group or individual therapy: 1) education about the biological and behavioral components of substance use disorders and PTSD; 2) guided implementation of information/emotion processing and self-regulation skills (see information on the FREEDOM skill sequence below); and 3) development of an autobiographical narrative that incorporates the trauma and PTSD. In the brief therapy form, individuals receive TARGET counseling in 12 weekly sessions, but treatment may 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), 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. TARGET also uses creative arts activities (such as making collages of personalized “lifelines,” drawing, poetry, and writing) for processing and managing related reactions to current stressful experiences (i.e., PTSD symptoms, traumatic grief, survivor guilt, shame, interpersonal rejection, and existential/spiritual alienation).

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 (Ford 2008; 2012).

Study

Ford and colleagues (2008) used a randomized controlled 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, Connecticut area. Exclusion criteria included having substantial cognitive impairment, being on suicide watch, and being younger than age 18. Inclusion criteria included parenting a child younger than age 5 and having a current diagnosis of partial or full PTSD. The 147 mothers were randomly assigned to one of three groups: 1) a waitlist, treatment-as-usual (TAU) comparison (n = 45); Present Centered Therapy (n = 53); or the trauma-focused psychotherapy program, TARGET (n = 49). The CrimeSolutions review of the study focused on the comparison between mothers in TARGET and mothers in the TAU group.

Participants in the study were 39 percent white, 33 percent Black (African/Caribbean American), and 28 percent Latina or mixed race. Most participants lived alone (42 percent had never married, and 22 percent were divorced, separated, or widowed). About 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. There were no statistically significant differences in baseline characteristics between mothers in the TARGET and TAU groups, except for emotion regulation and depression. The TARGET group had higher emotion regulation and lower depression scores, compared with TAU group mothers.

Outcomes of interest were PTSD symptoms, depression, anxiety, and emotion regulation. Symptoms were assessed prior to treatment and at posttreatment for the TARGET treatment and waitlist TAU comparison groups. PTSD was measured using the Clinician Administered PTSD Scale to assess diagnoses for full PTSD and partial PTSD. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (i.e., the DSM–IV–TR) was administered to assess anxiety. A 21-item Beck Depression Inventory (BDI) measured depression: scores greater than or equal to 19 indicated clinical-level depression, and scores greater than or equal to 30 indicated severe depression. The State–Trait Anxiety Inventory measured symptoms of anxiety using a 0–4 scale. Scores greater than 40 were considered clinical range, and scores greater than 50 were considered severe. Emotion regulation was measured through a 30-item Generalized Expectancies for Negative Mood Regulation Scale. Participants’ self-perceived ability to identify, manage, and utilize adaptively a variety of negative emotion states was assessed using a 1–5 scale (from strongly agree to strongly disagree).

A mixed method regression was used with covariates such as age, marital status, education, ethnicity, and comorbid psychiatric disorders controlled for within the intent-to-treat analysis. The study authors did not conduct subgroup analyses.

Study

Ford and colleagues (2012) conducted a randomized controlled trial involving delinquent girls (ages 13–17) who met the following criteria: 1) self-reported delinquency, based on National Delinquency Study criteria; and 2) full or partial posttraumatic stress disorder, based on the Clinician-Administered PTSD Scale for Children/Adolescents (CAPS–CA) structured diagnostic interview. Study participants were recruited from November 2006 to April 2008 in Hartford, Connecticut, from schools, health clinics, protective services offices, and residential treatment centers.

There were 59 delinquent girls who were randomized to either the treatment group, which received TARGET (n = 33), or to the Enhanced Treatment as Usual (ETAU) group (n = 26). The ETAU provided the girls with relational support in dealing with current life problems through clinical observations and helped them build a sense of emotional connection in healthy relationships. The female study participants were 59 percent Latina or mixed race, 25 percent white, 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, 45 percent were living in residential treatment facilities due to severe behavioral problems, and 37.5 percent had prior arrests for violent crimes. There were no statistically significant differences between the groups on demographic or outcome measures, except in symptoms of PTSD for Criterion B, at baseline. The TARGET group had a greater number of symptoms, compared with the ETAU group.

Data were collected at baseline and at a posttest interview (approximately 4 months after the baseline interview). The baseline assessment interviews were conducted 14 to 21 days before the girls began treatment. The outcomes of interest were the scores for PTSD diagnoses; for three diagnoses for PTSD (Criteria B, C, and D); and for emotion regulation, posttraumatic cognitions, anxiety, depression, anger, and hope.

Full and partial PTSD diagnoses were measured through the CAPS–structured interview, which assesses DSM–IV–TR categorical diagnoses for PTSD and rates the intensity and frequency of each PTSD symptom on a 0–4 scale ([0 = none; 4 = extreme distress] and [0 = never; 4 = daily or almost every day]). Ordinal symptom severity scores were calculated for the categorial diagnosis of PTSD for Criterion B (intrusion), Criterion C (avoidance), and Criterion D (hyperarousal). The 30-item Generalized Expectancies for Negative Mood Regulation Scale measured emotion regulation. Subscales from the 54-item Trauma Symptom Checklist for Children questionnaire were used to measure anxiety, depression, and anger (0 = never; 3 = almost all the time). Experiences of posttraumatic cognition were measured through a 36-item questionnaire on self-reported measures of posttraumatic beliefs related to the world, self, and self-blame. Hope was measured through a 6-item scale that assessed self-efficacy and optimism. A mixed model regression was used to analyze differences between adolescents in the TARGET and ETAU groups (which included all participants regardless of missing data). The study authors did not conduct subgroup analyses.

The Trauma Affect Regulation: Guide for Education and Therapy (TARGET) was delivered by female therapists who had doctoral degrees in clinical psychology or psychiatry; or who had master’s degrees in social work, counseling, or marriage and family therapy. Two therapists were also fluent in Spanish. In addition, TARGET screening for eligibility and baseline and posttherapy assessments was administered by experienced female research interviewers who were approved by the Institutional Review Boards of the University of Connecticut Health Center and the Connecticut Department of Children and Families (Ford et al. 2012).

Additional information for the TARGET program is also available from The National Child Traumatic Stress Network at https://www.nctsn.org/interventions/trauma-affect-regulation-guide-education-and-therapy.

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

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.

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.

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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Evidence Ratings for Outcomes

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Evidence Ratings for Outcomes

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Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?