Evaluation of the Effectiveness and Acceptability of a Phase-Based Treatment for Complex Post ...

172 Pages·2016·2.27 MB·English

Evaluation of the Effectiveness and Acceptability of a Phase-Based Treatment
for Complex Post-Traumatic Stress Disorder

Jennifer Readings
June, 2016

Submitted in partial fulfilment of the requirements for the degree of Doctor in Clinical
Psychology (DClinPsy), Royal Holloway, University of London.
Acknowledgements
First and foremost, thank you to Dr Gary Brown and Dr Jo Billings who
supervised me for this project. I am also grateful to the clinicians at Berkshire
Traumatic Stress Service who made such efforts with collection of measures, and to
Kathy Martin, Research Assistant. Thank you also to Dr Sharif El-Leithy for his
advice in the early stages of this project.

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Abstract
Sufferers of Post-Traumatic Stress Disorder (PTSD) caused by repeated or
prolonged traumas, such as childhood abuse or intimate partner violence, may have
symptoms that go beyond the normal clusters of symptoms seen in PTSD from single-
incident traumas. These can include emotional, interpersonal, dissociative and somatic
symptoms, and altered beliefs about the self, others and the world. This has been
termed Complex Post-Traumatic Stress Disorder (CPTSD). Recent expert guidelines
recommend that treatment for CPTSD should consist of several phases, not only
individual trauma-focused therapy.
This study is the first evaluation of a new phase-based treatment programme
for CPTSD, consisting, sequentially, of a psychoeducation group (Phase 1),
Compassionate Resilience group (CRG; Phase 2), and individual trauma-focused
therapy (Phase 3). The main research questions were: how effective is the treatment in
addressing both PTSD and CPTSD symptoms; and secondly, how acceptable is the
treatment to participants?
The study had two components: firstly, a case series analysis of nine
participants examining the effectiveness of the treatment, using measures of PTSD,
CPTSD and self-compassion. The second component was a thematic analysis of
interviews with six participants who had completed treatment, in order to explore the
acceptability of the programme.
Results from the case series analysis indicated that the treatment was effective
in reducing CPTSD, PTSD symptoms, and self-criticism. As predicted, visual
analysis of symptom scores suggested greater symptom improvement during Phase 2
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than Phase 1. Surprisingly, PTSD symptoms improved before Phase 3, with three
participants showing clinically-significant improvement by the end of Phase 2. The
thematic analysis indicated the treatment was highly acceptable to participants, with
over-arching themes identified regarding the experience of group format and
experience of phase-based treatment.
Overall, this study appeared to support the use of phase-based treatments for
CPTSD, and indicated that compassion-focused interventions may be an effective
component therein.

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List of Tables
Table 1: Data Collection Time Points and Measures ................................................... 46
Table 2: Treatment Content by Phase .......................................................................... 49
Table 3: Case Series Participant Characteristics .......................................................... 50
Table 4: Clinical Summary of Case Series Participants .............................................. 51
Table 5: P1 PHQ-9, GAD-7 and WSAS scores ........................................................... 55
Table 6: P2 PHQ-9, GAD-7 and WSAS scores ........................................................... 60
Table 7: P3 PHQ-9, GAD-7 and WSAS scores ........................................................... 65
Table 8: P4 PHQ-9, GAD-7 and WSAS scores ........................................................... 70
Table 9: P5 PHQ-9, GAD-7 and WSAS scores ........................................................... 75
Table 10: P6 PHQ-9, GAD-7 and WSAS scores ......................................................... 80
Table 11: P7 PHQ-9, GAD-7 and WSAS scores ......................................................... 85
Table 12: P8 PHQ-9, GAD-7 and WSAS scores ......................................................... 90
Table 13: P9 PHQ-9, GAD-7 and WSAS scores ......................................................... 95
Table 14: Thematic Analysis Participant Characteristics .......................................... 100

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List of Figures
Figure 1: Attrition from Case Series from Point of Assessment ................................. 40
Figure 2: BTSS Treatment Schedule Indicating Duration of Treatment Phases ......... 48
Figure 3: Reliable and Clinical Change for PCL-5 at Post-CRG ................................ 52
Figure 4: Reliable and Clinical Change for PCL-5 at Latest Available Data Point .... 53
Figure 5: P1 PCL-5 Total Score................................................................................... 56
Figure 6: P1 Complex PTSD Symptoms (BTSS CPTSD items & PCL-5 Item 9) ...... 57
Figure 7: P1 FCSRS Subscales: Hated Self, Inadequate Self, Reassured Self ............ 58
Figure 8: P2 PCL-5 Total Score................................................................................... 61
Figure 9: P2 Complex PTSD Symptoms (BTSS CPTSD items & PCL-5 Item 9) ...... 62
Figure 10: P2 FCSRS Subscales: Hated Self, Inadequate Self, Reassured Self .......... 63
Figure 11: P3 PCL-5 Total Score................................................................................. 66
Figure 12: P3 Complex PTSD Symptoms (BTSS CPTSD items & PCL-5 Item 9) .... 67
Figure 13: P3 FCSRS Subscales: Hated Self, Inadequate Self, Reassured Self .......... 68
Figure 14: P4 PCL-5 Total Score................................................................................. 71
Figure 15: P4 Complex PTSD symptoms (BTSS CPTSD items & PCL-5 Item 9) .... 72
Figure 16: P4 FCSRS Subscales: Hated Self, Inadequate Self, Reassured Self .......... 73
Figure 17: P5 PCL-5 total score................................................................................... 76
Figure 18: P5 Complex PTSD symptoms (BTSS CPTSD items & PCL-5 Item 9) .... 77
Figure 19: P5 FCSRS Subscales: Hated Self, Inadequate Self, Reassured Self .......... 78
Figure 20: P6 PCL-5 Total Score................................................................................. 81
Figure 21: P6 Complex PTSD Symptoms (BTSS CPTSD items & PCL-5 Item 9) .... 82
Figure 22: P6 FCSRS subscales: Hated Self, Inadequate Self, Reassured Self ........... 83
Figure 23: P7 PCL-5 Total Score................................................................................. 86
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Figure 24: P7 Complex PTSD Symptoms (BTSS CPTSD items & PCL-5 Item 9) .... 87
Figure 25: P7 FCSRS Subscales: Hated Self, Inadequate Self, Reassured Self .......... 88
Figure 26: P8 PCL-5 Total Score................................................................................. 91
Figure 27: P8 Complex PTSD Symptoms (BTSS CPTSD items & PCL-5 Item 9) .... 92
Figure 28: P8 FCSRS Subscales: Hated Self, Inadequate Self, Reassured Self .......... 93
Figure 29: P9 PCL-5 Total Score................................................................................. 96
Figure 30: P9 Complex PTSD Symptoms (BTSS CPTSD items & PCL-5 Item 9) .... 97
Figure 31: P9 FCSRS Subscales: Hated Self, Inadequate Self, Reassured Self .......... 98

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Table of Contents
Chapter 1: Introduction ................................................................................................ 10
Diagnostic Status of CPTSD .................................................................................... 12
Origins of CPTSD .................................................................................................... 13
CPTSD: A Separate Diagnosis? ............................................................................... 15
Do People with CPTSD need Different Treatment to People with PTSD? ............. 18
Why Phase-based Treatment? .................................................................................. 21
Existing Phase-based Treatments for CPTSD .......................................................... 24
Theoretical Basis of Compassion-focused Interventions for PTSD......................... 26
Evidential Basis for Compassion-focused Interventions in PTSD .......................... 28
Limitations of Research Literature ........................................................................... 30
The Case for CPTSD Research ................................................................................ 33
The Present Study..................................................................................................... 34
Chapter 2: Methods ...................................................................................................... 38
Participants ............................................................................................................... 38
Attrition .................................................................................................................... 39
Ethics ........................................................................................................................ 40
Design....................................................................................................................... 41
Measures................................................................................................................... 41
Procedure .................................................................................................................. 45
Treatment Content .................................................................................................... 48
Chapter 3: Results of Case Series ................................................................................ 50
Pre-Post Changes in PTSD Symptomology ............................................................. 51
Participant 1.............................................................................................................. 53
Participant 2.............................................................................................................. 59
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Participant 3.............................................................................................................. 64
Participant 4.............................................................................................................. 69
Participant 5.............................................................................................................. 74
Participant 6.............................................................................................................. 79
Participant 7.............................................................................................................. 84
Participant 8.............................................................................................................. 89
Participant 9.............................................................................................................. 94
Chapter 4: Results of Thematic Analysis................................................................... 100
Experience of Group Treatment ............................................................................. 102
Experience of Phase-based Treatment ................................................................... 110
Chapter 5: Discussion ................................................................................................ 119
Effectiveness of the Treatment Programme ........................................................... 119
Phase 1: Psychoeducation ...................................................................................... 121
Phase 2: Compassionate Resilience Group ............................................................ 122
Phase 3: Individual Trauma-Focused Therapy....................................................... 124
Group Format ......................................................................................................... 126
Strengths of Study .................................................................................................. 127
Limitations ............................................................................................................. 129
Future Research ...................................................................................................... 135
Clinical Implications .............................................................................................. 137
Conclusion .............................................................................................................. 138
References .................................................................................................................. 140
Appendices ................................................................................................................. 153
Appendix A: REC Conditional approval ............................................................... 153
Appendix B: REC Approval confirmation ............................................................. 158
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Appendix C: Berkshire NHS R&D approval ......................................................... 160
Appendix D: Royal Holloway Departmental Ethics Committee approval ............ 161
Appendix E: PCL-5 ................................................................................................ 162
Appendix F: BTSS CPTSD measure ..................................................................... 163
Appendix G: FCSRS .............................................................................................. 164
Appendix H: Interview schedule ............................................................................ 165
Appendix I: Participant Information Sheet ............................................................ 167
Appendix J: Participant consent form .................................................................... 169
Appendix K: Sample of Coded Transcript 1 .......................................................... 170
Appendix L: Sample of Coded Transcript 2 .......................................................... 171

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