This study examined longitudinal outcomes for female veterans enrolled in the Renew sexual trauma treatment program over 12 months. It found that symptoms of PTSD and negative cognitions decreased after treatment, while self-esteem and quality of life increased, with improvements sustained at 12 months. Specifically: 1) Post-traumatic symptoms decreased and positive factors like self-esteem increased immediately after the 12-week Renew program. 2) These beneficial changes were maintained when assessed at 6, 9, and 12 months post-treatment. 3) The Renew program, which incorporates principles of holographic reprocessing therapy, appears to be an effective long-term treatment for female veterans with histories of multiple traumas.

1. ORIGINAL PAPER
Longitudinal Outcomes of Women Veterans Enrolled
in the Renew Sexual Trauma Treatment Program
Lori S. Katz • Geta Cojucar • Rani A. Hoff •
Claire Lindl • Cristi Huffman • Tara Drew
Published online: 19 November 2014
Ó Springer Science+Business Media New York (outside the USA) 2014
Abstract Forty-three female veterans who were starting
the 12 weeks Renew treatment program for survivors of
sexual trauma at a Department of Veterans Affairs medical
center were recruited for this study. Forty-one participants
enrolled in a within subjects design longitudinal study.
Participants completed structured interviews at pre-treat-
ment (baseline) and post-treatment, and at 6, 9, and
12 months from baseline. Thirty-seven completed the
treatment (10 % dropout) and 32 completed the entire
study. Similar to previous findings on Renew, posttrau-
matic symptoms decreased immediately after graduation
with large to medium effect sizes. In addition, up to 70 %
had reliable clinical change at the 95 % confidence inter-
val. However, the main hypothesis of this study was to test
the stability of treatment outcomes at 12 months from
baseline. Not only were these changes sustained 12 months
from baseline, positive factors of self-esteem and quality of
life continued to increase over time. Given participants’
level of trauma and their chronicity of symptoms prior to
Renew, results suggest that Renew is an effective treatment
for female veterans with multiple traumas across the life
span including military sexual trauma, and a variety of life
stressors including homelessness, substance abuse, and
medical problems.
Keywords Sexual trauma Á Women veterans Á Military
sexual trauma Á Holographic reprocessing
This study is a longitudinal outcome study following female
veterans who were enrolled in the 12 weeks Renew sexual
trauma treatment program over the course of 1 year. Renew
is designed to address sexual trauma, including military
sexual trauma (MST) for veterans with complex histories of
trauma across the life span and a variety of life stressors
including homelessness, substance abuse, and chronic med-
ical conditions (see Katz et al. 2014a). The goals of Renew
are to (1) help participants improve coping skills, (2) identify
trauma-induced interpersonal patterns, (3) reappraise the
meaning of living through trauma, (4) release negative affect
and regain positive affect, and (5) build a more positive self-
perception and optimistic vision for the future.
A preliminary outcome study examined 112 female
veterans enrolled in Renew (Katz et al. 2014a). Of these,
97 graduated (13 % dropout rate). Graduates of the pro-
gram reported a significant reduction in posttraumatic
stress disorder (PTSD: APA 1994), psychiatric symptoms,
and posttraumatic negative cognitions (up to 60 % had
reliable clinical change at the 95 % confidence interval),
and significant increases in self-esteem, optimism, and
satisfaction with life with large to moderate effect sizes.
Although these data are promising, further research is
needed to determine if these results are sustained over time.
This study assessed veterans via 90 min structured clinical
This study was conducted at the VA Long Beach Healthcare System.
The Renew treatment manuals and Facilitator’s Handbook are
available upon request by contacting the first author.
L. S. Katz (&)
VA Puget Sound Health Care System, 9600 Veterans Drive SW,
Tacoma, WA 98493, USA
e-mail: Lorikmail@yahoo.com
L. S. Katz
University of Southern California, Los Angeles, CA, USA
G. Cojucar Á C. Lindl Á C. Huffman Á T. Drew
VA Long Beach Healthcare System, Long Beach, CA, USA
R. A. Hoff
VA Connecticut Healthcare System, and Yale University,
New Haven, CT, USA
123
J Contemp Psychother (2015) 45:143–150
DOI 10.1007/s10879-014-9289-5

2. interviews at five 3 month intervals: at baseline (pre-
treatment); 3-months (post treatment); and 6, 9, and
12 months from baseline. There were two goals of this
study: (1) to determine if the original findings were repli-
cated; and (2) if so, are these improvements sustained at
12 months from baseline. Although other time periods
were assessed, the target of this study is to examine the
long-term outcome of Renew treatment from post-treat-
ment to 12 months from baseline.
The Renew Program
Renew is: (1) an integrated curriculum where each of the
classes and activities are designed to complement and
deepen the process; (2) it is a holistic approach engaging
the mind and body; (3) it provides coping skills for
addressing sleep, affect regulation (anxiety, triggers, anger/
resentment, and grief), resolving self-blame, and improving
communication; and (4) it addresses interpersonal dys-
function by targeting trauma-related perceptions and feel-
ings that replay themselves in relationships with others.
Weekly topics include: defining sexual trauma, sleep and
nightmares, triggers and anxiety, anger and resentments,
remembering trauma, relationship patterns, self-blame and
shame, losses and grief, healthy intimate relationships,
communication skills, and meaning, purpose and joy.
The program was delivered in a group setting by cohort
(e.g., same group members throughout the program) and
met for 4 hours a day Monday–Friday. Morning opening
exercises (e.g., interactive games exploring movement,
sound, imagination, or teamwork) help build a sense of
community, safety, trust, and being in the present moment.
Each class provides didactic information, encourages dis-
cussion, and usually includes a self-exploratory writing
exercise. All participants receive their own Renew work-
books that they were able to keep at the end of the program.
In addition to the core curriculum, weekly adjunctive
activities were offered such as yoga, art therapy, relaxation
skills, self-care, and recreational outings. These activities
followed the same theme of the week creating a cohesive
and integrated healing experience. For example, on the
week of nightmares, participants made nightmare sachets,
and dream catchers in art therapy, and they learned
restorative calming poses in yoga (see Katz et al. 2014a).
Treatment Approach
In addition to providing coping skills to manage trauma,
Renew delves into interpersonal issues, where MST may
have disrupted the ability to form secure relationships with
others. By definition, MST is an interpersonal trauma, often
characterized by betrayal, shame, and lack of support from
others—leading to unrealistic self-blame, difficulty trusting
others, and avoidance of emotional and physical intimacy.
Sexual trauma survivors may develop enduring perceptions
of themselves, others, and the world and associated coping
strategies that unconsciously lead to re-experiencing and
replicating certain interpersonal dynamics. Thus, without
being aware, survivors may find themselves repeating
certain abuse dynamics in multiple relationships over time.
Because of the interpersonal nature of sexual trauma,
Renew is primarily grounded in the principles of the
interpersonal trauma treatment called holographic repro-
cessing (HR) (Katz 2001, 2005; Katz et al. 2008, 2014b;
Basharpoor et al. 2011). HR is an emerging evidence-based
treatment that helps participants identify emotional themes
and interpersonal patterns. Initial empirical studies exam-
ining the outcomes using HR, found significant decreases
in posttraumatic symptoms with large effect sizes and
remarkably low dropout rates (Katz et al. 2008, 2014b;
Basharpoor et al. 2011). Two randomized clinical trials
found that HR was equally as effective as Prolonged
Exposure (PE: Foa et al. 2007) and Cognitive Processing
Therapy (CPT: Resick and Schnicke 1996), both popular
cognitive-behavioral treatments for trauma, but with lower
dropout rates (Basharpoor et al. 2011; Katz et al. 2014b).
Compared with other treatments for trauma, in HR, there
is no exposure component. Rather than identifying a spe-
cific event of trauma, participants examine how living
through trauma has influenced reenactments in relation-
ships. HR focuses on healing the internal working model
that forms as a result of trauma and maltreatment. This is
similar to addressing participant’s underlying attachment
style (Bowlby 1969, 1973; Ainsworth 1969; and Main and
Solomon 1986). In HR, the internal working model and
theme of reenactments that stem from the model are termed
experiential holograms (also referred to as holograms).
According to HR theory, some common holograms are
neglect, rejection, betrayal, and endangerment. One of the
techniques to produce change is for clients to examine
oneself and trauma-related circumstances in its context.
Similar to narrative therapy, this moves the conceptuali-
zation of trauma from something personal (e.g., it hap-
pened because of the client) to one that is impersonal and
includes other people’s agendas and motives distinct from
anything about the client. These shifts occur by considering
context, multiple points of view, understanding what hap-
pened with hindsight advantage and from the perspective
of one’s current age. Participants come to realize that their
thoughts, feelings, and behaviors may have ‘‘made sense’’
given the context of their holograms, but that their past
trauma no longer has to define or dictate their current
beliefs or future behavior. Through perspective taking, and
reframing they can have global shifts about their under-
standing of themselves and others.
144 J Contemp Psychother (2015) 45:143–150
123

3. In Renew, participants identify their own interpersonal
themes and consider how this was situational rather than
personal (e.g., not their fault). In subsequent weeks, they
write a letter to their younger-self such as communicating
understanding, encouragement, forgiveness, and/or sup-
port. Then, they engage in imaginal reprocessing (Katz
2005). This is an imagery-based exercise where partici-
pants remain anchored to their current age-self and imagine
visiting their younger-self. This is a similar technique used
by Smucker and Dancu (1999) but it is delivered in a group
where each person guides their own imagery of what they
would like to say to their younger-self and what they would
like to do (e.g., give her a hug, or bring her to a garden).
Participants learn that their trauma-based perceptions
are distinct from their true identity and distinct from what
is possible and who they can choose to be. This sets the
stage for participants to develop new internal working
models about themselves, others, and the world. With a
new self-perception, they are equipped to consider how
they may want to move forward in their lives. Participants
are also encouraged to consider topics such as ‘‘their pur-
pose’’ and how they are a unique contribution to the world.
In summary, it was hypothesized that Renew graduates
would have significant reductions in negative symptoms
(posttraumatic negative cognitions and PTSD), and
increases in positive factors (self-esteem and quality of
life) immediately after graduation of the program and that
these changes would be sustained at 12 months from
baseline.
Method
Participants
Forty-three female veterans who had sexual trauma histo-
ries and were enrolled in the Renew treatment program at a
Department of Veterans Affairs medical center women’s
mental health clinic were recruited for the study. Forty-one
enrolled in the study and completed the baseline intake
interview, 37 completed the 3 months follow up, 35 com-
pleted the 6 months follow up, 28 completed the 9 months
interview (four were scheduled too late for the 9 months
interview but were added to the 12 months follow up), and
32 completed the 12 months follow up (see Fig. 1). The
average age was 47 (range from 21 to 67, SD = 9.37). This
sample of female veterans had a complex history of trauma
with multiple events across the lifespan, 79 % with sub-
stance abuse in recovery, and 95 % with PTSD as assessed
by their treating clinicians. Sixty-four percent had recently
experienced homelessness and were housed at United
States Veterans Initiative housing program. None had jobs
and 42 % had disability income. Fifty-one percent of the
women had high school degrees, 28 % has associates
degrees, and 21 % completed college or graduate school.
Other demographic factors that we assessed were branch of
service, ethnicity, marital status, and sexual trauma histo-
ries (see Table 1).
Measures
All Measures were Delivered Via a Structured Face
to Face Interview
Demographic Information
In the structured interview, general information was gath-
ered regarding age, ethnicity, substance abuse, medical
history, trauma history including military, childhood, and/
or adult abuse, and domestic violence. Other questions
about housing and money management were asked but not
used in this study.
Posttraumatic Negative Thinking
The 33-item posttraumatic cognitions inventory (PTCI)
(Foa et al. 1999) was used to assess trauma-related
thoughts and beliefs. The PTCI has three subscales: neg-
ative cognitions about the self, negative cognitions about
the world, and self-blame as well as a global scale, Total
negative cognitions, which is the sum of the three sub-
scales. Items are rated using a seven-point Likert-type
response scale that ranges from 1 = totally disagree, to
7 = totally agree. Negative thinking scores are computed
by adding the items in each subscale, with higher scores
indicating higher ratings of negative thinking. The PTCI
has demonstrated good reliability: internal consistency,
(a = .86 to .97); test–retest reliability (1 week interval .75,
.89, 3 weeks interval .80 to .86); and convergent validity
(sensitivity = .78, specificity = .93) (Foa et al. 1999).
Internal consistency for this measure in this sample at pre-
and post-treatment was a = .95, and a = .96, respectively.
Posttraumatic Stress Disorder
The 17-item post-traumatic checklist (PCL) (Weathers
et al. 1993) was used to assess symptoms of PTSD using
items consistent with the Diagnostic and Statistical Manual
IV (DSM-IV; APA 1994) criteria for PTSD. Items are
answered on a five-point Likert-type scale, where 1 = not
at all, and 5 = extremely. A general measure of PTSD is
indicated by the sum of the items in the scale, whereby a
higher score is related to a higher level of PTSD. The scale
has good reliability based on test–retest reliability (r = .96
at 2–3 days and r = .88 at 1 week; Blanchard et al. 1996)
J Contemp Psychother (2015) 45:143–150 145
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4. and internal consistency (a = .94 and .97; Blanchard et al.
1996; Weathers et al. 1993). The PCL also correlates
positively with the Mississippi PTSD scale (convergent
validity r = .85 and .93; Weathers et al. 1993). Internal
consistency for this measure in this sample at pre- and post-
treatment was a = .93, and a = .96, respectively.
Positive Psychological Factors
Positive factors were measured by two scales: Rosenberg’s
Self-esteem Scale (RSES; Rosenberg 1965), and Deligh-
ted-Terrible Life (DTL: Andrews and Withey 1976). The
RSES is an 11-item scale that measures self-esteem.
Respondents use a four-point Likert-type scale where
1 = Strongly agree, and 4 = Strongly disagree to state-
ments such as ‘‘On the whole, I am satisfied with myself’’
and ‘‘I feel that I have a number of good qualities.’’ RSES
has an internal consistency of a = .77, and a minimum
coefficient of reproducibility of at least a = .90 (Rosen-
berg 1965). Internal consistency for this measure in this
sample at pre- and post-treatment was a = .84, and
a = .90, respectively. Delighted-Terrible Life is a single
item question to assess quality of life: ‘‘How do you feel
about your life as a whole?’’ rated on a 7-point scale from
7 = delighted to 1 = terrible.
Procedure
This study recruited those who were accepted and enrolled
in the Renew treatment program. Criteria for admission to
Renew: All potential participants for Renew were screened
for their readiness to benefit from the program via a written
application and interview. A referring VA clinician was
also required to complete a Verification Form, which
involved verifying (by the clinician’s initials) that the
participant met the admission criteria of each of the fol-
lowing items: (1) female veteran with a history of sexual
trauma; (2) a minimum of 90 days clean and sober; (3) a
minimum of 6 months with no suicide attempts; (4) a
minimum of 6 months with no psychiatric hospitalization;
and (5) the ability to complete the entire program without
interruption. Efforts were made to include as many appli-
cants as possible and less than 10 % were not accepted into
the program. Some of these had a delayed admission to
Renew after accumulating increased sobriety and stability.
Follow Up Interviews
37 Completed
3 Month
Follow Up
(post-treatment)
35 Completed
6 Month
Follow Up
9 (22%)
Dropped out
of the study
from baseline
4 (10%)
Dropped out of
treatment
43 Enrolled in
study
41 Completed
Baseline
(Pre-treatment)
28 Completed
9 Month
Follow Up
5 (13.5%)
Dropped out
Post-
treatment
32 Completed
12 Month
Follow Up
Fig. 1 Sample characteristics over the course of the study
146 J Contemp Psychother (2015) 45:143–150
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5. All applicants needed to be stable prior to admission
including secure housing, stable medication regime, and
without pending legal or health appointments that could
interfere with Renew.
During Renew orientation, participants were asked if they
wanted to enroll in this study. Enrolling in this study was
optional and had no bearing on participation in Renew.
Those who were interested were consented for the study and
completed an Internal Review Board (IRB) approved
Informed Consent Form and HIPAA form and were sched-
uled for their first 90 min interview. At the time of the
interview, participants were asked for a urine toxicology
screening performed in the clinic. At the end of the interview
they were given a voucher to turn in at the Agent Cashier on
campus for a $15 payment. Participants were contacted via
telephone at 3 months intervals to come in for another
structured 90 min interview, urine toxicology screen, and
payment. Six people completed interviews: including 2
volunteer research assistants, 2 psychology technicians, and
2 clinical psychologists. A licensed clinical psychologist
(first author) was physically on station and available should
any questions or issues of concern arise during the interview
(e.g., concerns of dangerousness or any behavioral or verbal
responses in need of further clinical evaluation).
This study was part of a multi-site study funded through
the VA Special Needs Grant and Per Diem under the VA
Homeless providers Grant and Per Diem Program, Women
and Women in the care of dependent children. It was
designed and overseen by the North East Program Evalu-
ation Center (NEPEC). The data at this site was processed
independently as per the agreement with the research team
at NEPEC prior to the study. The local IRB monitored the
study and no adverse events were reported.
Treatment and Data Collection Fidelity
Participants in this study were collected across seven
cohorts of Renew conducted over the course of 3 years,
with total data collection time of 4 years. Thus, treatment
and data collection fidelity was important to make sure that
all procedures were implemented consistently and accu-
rately. Several strategies were used to ensure treatment
fidelity as discussed in Katz et al. (2014a). To summarize:
(1) Renew is delivered via a structured course manual (e.g.,
Renew workbooks) with a corresponding facilitator’s guide
to make sure appropriate material was presented at each
scheduled time. (2) The first author, who developed the
curriculum, was present for each cohort and taught the
majority of the classes as well as provided supervision to
trainees who participated in the program. (3) The first
author led weekly 1 hour meetings with providers to dis-
cuss patient progress, logistics, and making sure that
Renew was being implemented consistently and appropri-
ately. (4) No changes to the curriculum were allowed
during the study. (5) All participants had to pass a 25-item
short-answer final exam in order to graduate Renew with a
minimum score of 80 %.
Efforts for data collection fidelity ensured consistent and
accurate data collection procedures. First, all research
assistants were trained in delivering the structured inter-
view. This consisted of (1) reviewing the written materials;
(2) observing a trained psychologist deliver the interview;
and (3) being observed giving the interview. The interview
was straight-forward consisting of asking the questions in
sequential order. Secondly, a spread sheet kept track of
participants and their interview schedule. A research
coordinator monitored the spreadsheet to ensure appropri-
ate follow-up was being conducted. She documented when
participants were contacted, scheduled, and completed an
interview. She also documented who conducted each
interview and if participants were given their payment
voucher. Third, a binder of data was created for each
participant (only identified by a code) with the five inter-
views separated by dividers (kept in a double locked
location) to keep the data organized.
Missing Data
Although methods such as last observation carried forward
or intent to treat are often used to impute missing data in
Table 1 Description of the total sample (N = 43) where numbers
indicate a positive response to each item
# (%)
Branch of service
Army 24 (56)
Navy 14 (33)
Air force 4 (9)
Marines 1 (2)
Ethnicity
Caucasian 24 (55)
African American 14 (33)
Hispanic 3 (7)
Other 2 (5)
Marital status
Single 12 (28)
Married 5 (12)
Divorced 25 (58)
Widow 1 (2)
Trauma exposure
MST 37 (86)
Child abuse 32 (74)
Adult abuse 24 (56)
Domestic violence 28 (65)
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6. clinical trials, we did not employ these methods as they
could bias the results towards a more stable linear curve
(e.g., decrease potential differences from post-treatment to
12 months time points). This would bias results in favor of
our hypothesis of finding no change from these time points.
Thus, a more conservative approach is to constrict the
analyses to the completers to minimize over or under-
estimating results. Fortunately, only five participants
dropped from the 3 to 12 months time intervals. Also, four
participants had difficulty scheduling their 9 months
interview and the delay was greater than 6 weeks (ren-
dering them closer to their 12 months appointment), so we
opted to skip their 9 months interview, wait a few weeks
and collect their 12 months interview instead.
Results
Completion Rate
Forty-one female veterans enrolled in this study, completed
the baseline interview and engaged in the Renew treatment
program. Thirty-seven of the participants completed treat-
ment (10 % dropout). Of these graduates, 32 completed the
entire 12 months study (see Fig. 1). A total of 173 inter-
views were completed over the course of 4 years.
Pre- to Post-Treatment Differences
Using an analysis of variance (ANOVA) within-subjects
repeated measures design, each variable was examined
across the five time points. Variables for posttraumatic
thoughts (PTCI), posttraumatic symptoms (PCL) and
quality of life (DTL) yielded significant ANOVAs (PTCI:
F(1.35) = 28.45, p .001; PCL: F(1.25) = 4.49, p .05;
DTL: F(1.30) = 10.68, p .01). The ANOVA for self-
esteem (RSES) across the 5 time points was not significant.
However, when we re-ran the repeated measures ANOVA
for RSES including only the three time points of interest
(baseline, 3 and 12 months) the ANOVA was significant,
(RSES: F(1.34) = 5.98, p .05). Therefore, we opted to
explore our theory-driven planned comparisons for all
variables including the RSES. We only ran the planned
comparisons that fit our hypotheses thus significantly
reducing the family-wise error rate. We compared three
time periods: baseline, 3 and 12 months from baseline.
Furthermore, a conservative approach is to use a correction
to the significance level .05/c where c = k(k - 1)/2, and
k = number of means compared. In this case, if three time
periods are included, then c = 3(2)/2 = 3, and .05/
3 = .017. Thus, the corrected significance level for these
comparisons would be .017. Planned comparisons revealed
that from baseline to post-treatment, symptom reports of
posttraumatic thoughts and posttraumatic symptoms
showed significant decreases and quality of life showed
significant increases (see Table 2 for means, standard
deviations, t test, and Cohen’s d results). Analyses pro-
duced large to medium effect sizes as measured by Cohen’s
d, where Cohen (1988) gives approximate cutoffs defining
‘‘large’’ as d = .80, and ‘‘medium’’ as d = .50. Self-
esteem showed a marginal increase over time. Planned
comparisons revealed similar results from baseline to post-
treatment as from baseline to 12 months follow-up (see
Table 2) and no differences from post-treatment to
12 months from baseline, except for the positive factors
which continued to trend in an increased positive direction
over time. Specifically, quality of life continued to steadily
increase over time.
Reliable Change
Reliable change (RC) was calculated to determine if par-
ticipant’s scores changed sufficiently such that the change
is unlikely due to measurement unreliability. RC scores
were calculated using the total negative cognitions scale of
the PTCI as this was our primary target measure and
yielded the strongest results. Based on the procedures
outlined in Jacobson and Truax (1991), reliable change
scores were calculated: where RC = (post–pre scores)/
Sdiff, where Sdiff = H2 (standard error)2
, and the standard
error = SD H1-r (reliability). Consistent with Jacobson
and Traux (1991), the standard deviation used in these
analyses was the pretreatment experimental group
(SD = 37.56). Consistent with classical reliability theory,
Cronbach’s alpha was used from this sample (r = .95).
Therefore, Sdiff = 11.88. Confidence intervals at 95 %
were calculated by multiplying Sdiff by 1.96. Pre- to post-
treatment change scores would need to exceed -23.28 to
be considered reliably changed or significantly greater than
what would be expected by test–retest alone. From pre- to
post-treatment 26 participants (70 %) had reliable decrea-
ses on this measure.
Discussion
In order to evaluate the long term effects of the Renew
treatment program a longitudinal within subjects designed
study was implemented consisting of interviewing partici-
pants at baseline, post-treatment, and at 6, 9, and
12 months from baseline. Similar to previous research
findings, posttraumatic symptoms decreased immediately
after completion of the treatment (Katz et al. 2014).
However, the main hypothesis of this study is to test the
stability of treatment outcomes at 12 months from baseline.
As hypothesized, the results remained stable with means of
148 J Contemp Psychother (2015) 45:143–150
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7. self-esteem and quality of life trending in an increased
positive direction at 12 months from baseline.
For a longitudinal study of this magnitude, there were
surprisingly relatively few dropouts. First of all, there were
few dropouts of the treatment itself (only 10 % in this
study) which is below the dropout rate for treatments for
trauma in general, which appear to have about a 20–35 %
dropout rate (Hembree et al. 2003) and far below Pro-
longed Exposure (PE: Foa et al. 2007) and cognitive pro-
cessing therapy (CPT: Resick and Schnicke 1996) (e.g.,
26 % in Hembree et al. 2003, pp. 34–40; 5 % in Foa and
Rauch 2004, p. 38; 6 % in Nishith et al. 2002; 38 % in
Schnurr et al. 2007; and 46 % in Schnurr et al. 2003, 68 %
in Garcia et al. 2011; and 72 % in Zayfert et al. 2005).
However, results of this study are consistent with the
dropout rates found in studies on HR and Renew (e.g., 0 in
Katz et al. 2008, 10 % in Basharpoor et al. 2011, 6 % in
Katz et al. 2014b, and 13 % in Katz et al. 2014a).
In addition, there was a low dropout over time. When
participants were informally asked what kept them in the
study, there seemed to be three popular responses: (1) the
small payment may have been an incentive associated with
continued participation; (2) they mentioned positive factors
about the staff who kept track of participants and main-
tained a friendly rapport with them; and (3) participants
wanted to contribute to a study to give back to other
veterans.
Longitudinal studies have limitations in that there is an
increased risk that over time something may influence
results, typically in a negative way (e.g., life stressors, loss,
accidents, health challenges) but it is also possible that
positive life events could influence the results (e.g.,
continued therapy, new relationships, new jobs or promo-
tions). An interesting result in this study was the continued
trend in positive factors (self-esteem and quality of life)
that appears to improve over time. Maybe if participants
continue to feel good (with decreased symptoms) and
engage in positive activities in life, positive factors will
continue to improve. In contrast to a depressive downward
spiral, it appears that graduates have engaged in an upward
spiral. It is possible that life engagement may improve self-
esteem leading to further life engagement and increased
quality of life.
Further limitations of this study are a lack of detailed
data regarding life events and activities. It would be
meaningful to see if participants are indeed engaging in
more activities, although anecdotally, we were informed
that most of the participants were going back to school,
getting jobs, and/or volunteering. A future study could
include a comparison group to control for non-specific
psychotherapy factors such as group affiliation/socializa-
tion, attention, and time.
Nonetheless, that negative symptoms did not return after
a prolonged period suggests that Renew is an effective
treatment to reduce PTSD symptoms and increase positive
factors such as self-esteem all of which may contribute to
an improved quality of life.
Conclusions
This was a longitudinal study examining the outcomes of
the Renew treatment program designed to treat sexual
trauma and MST. In a sample of female veterans, the
Table 2 Repeated measures ANOVA, means, standard deviations, and planned comparison t tests from baseline to 3 months and baseline to
12 months interviews with pairwise correction
Baseline 3 months 12 months
M (SD) M (SD) M (SD) t test@3 d t test@12 d
PTCI
Total 140.78 (37.56) 98.58 (38.20) 100.11 (42.37) -6.27*** 1.11 -6.12*** 1.02
Neg thts self 85.11 (27.98) 56.03 (25.22) 56.86 (29.62) -6.24*** 1.09 -6.28*** .98
Neg thts world 36.19 (7.35) 30.22 (10.75) 30.72 (10.88) -3.55*** .66 -3.19** .60
Self blame 19.47 (8.77) 12.33 (7.60) 12.53 (6.67) -4.92*** .87 -4.64*** .90
PCL
58.89 (13.75) 46.19 (16.69) 47.34 (16.38) -4.32*** .83 -3.46** .77
Self-esteem
41.87 (15.16) 46.38 (13.96) 49.13 (13.12) 1.84 2.26
Quality of life
4.00 (1.34) 4.37 (1.35) 4.90 (1.36) 2.06 3.25 (p = .02) .67
Multiple planned comparisons used a significance level cut-off with correction .05/3 = .017
d = Cohen’s d, where d [ .80 is ‘‘large’’ and d [ .50 is ‘‘medium,’’
* p .017; ** p .01; *** p .001
J Contemp Psychother (2015) 45:143–150 149
123

8. Renew treatment program produced robust decreases in
negative symptoms with large to medium effect sizes and
with 70 % of the sample having reliable clinical change.
These changes were sustained 12 months from baseline
with trends for continued increases in positive factors of
self-esteem and quality of life.
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