Where do we start recovery?
Sep 29, 2012
My website reviews the nature of the disorder frequently associated with childhood experience of repeated or prolonged experiences of traumatization -- Complex Trauma, in adults, Developmental Trauma Disorder, in children -- [LINK] -- compares Complex Trauma to Posttraumatic Stress Disorder PTSD, and reviews expert guidelines for the treatment of both Complex Trauma and PTSD. However, there has been some need for identifying "enabling therapy" -- therapy needed to prepare the person for taking part in more intensive, often exposure-based, therapy. This is especially important given that a component difficulty experienced by those with Complex Trauma is emotion dysregulation -- difficulty regulating emotional response to troubling experiences, with such difficulty often resuling in premature attrition, or "dropping out" of therapy. One approach has been emotion regulation therapy -- and a handbook for that is provided via my site. Another approach has been more "cognitive" rather than strictly behaviorally or mindfulness oriented therapy. This cognitive approach has been trialed by Ethy Dorrepaal and her colleagues (2010) -- [LINK]. This study has now been replicated in a multi-site randomized clinical trial (2012) -- [LINK].
This is the first randomized controlled trial to test the efficacy of psycho-educational and cognitive behavioural stabilizing group treatment in terms of both PTSD and complex PTSD symptom severity. Seventy-one patients with complex PTSD and severe comorbidity (e.g. 74% axis II comorbidity) were randomly assigned to either a 20-week group treatment in addition to treatment as usual or to treatment as usual only. Primary outcome measures were the Davidson Trauma Scale (DTS) for PTSD and the Structured Interview for Disorders of Extreme Stress (SIDES) for complex PTSD symptoms. Statistical analysis was conducted in the intention-to-treat (ITT) and in the completer sample. Subjects were considered responders when scoring at 20 weeks at least 1 standard deviation below pretest find-ings. Results:The 16% attrition was relatively low. After 20 weeks, the experimental condition (large effect sizes) and control condition (medium effect sizes) both showed significant decreases on the DTS and SIDES, but differences between the conditions were not significant. The secondary responder analysis (ITT) revealed significantly more responders on the DTS (45 vs. 21%), but not on the SIDES (61 vs. 42%). Conclusions: Adding psycho-educational and cognitive behavioural stabilizing group treatment for complex PTSD related to child abuse to treatment as usual showed an equivocal outcome. Patients in both conditions improved substantially during stabilizing treatment, and while significant superiority on change scores was absent, responder analysis suggested clinical meaningfulness of adding group treatment.
Thus, this study serves as a further indication that cognitive and behaioural treatments, as used in this study, by themselves, are not sufficient to equip patients with the more complex problems associated with Complex Trauma Disorder and that, as suggested on the Complex Trauma page on my website, additional interventions are likely required, likely targeting those difficulties identified in individualized, and more comprehensive, assessment. However, given that comprehensive treatment for Complex Trauma is both complex and protracted, at least those interventions used in this study seem to have adequately managed the problem of attrition -- thus the subject of this post -- where do we start recovery -- by identifying those factors associated with attrition and targeting those factors early in treatment.