Exposing therapists to trauma-focused treatment in psychosis: effects on credibility, expected burden, and harm expectancies

Making meaning of trauma in psychosis

Background

Finding new meaning and identity in the aftermath of trauma has been identified as a key process of mental health recovery. However, research indicates that this meaning-making process is compromised in people with psychosis. Considering the high prevalence, yet under-treatment of trauma in people with psychosis, it is urgent to gain insight into how their meaning-making process can be supported.

Aim

To gain insight into how people with psychosis make meaning of trauma and identify barriers and facilitators in their meaning-making process.

Methods

Qualitative inquiry of N = 21 interviews transcripts from the Dutch Psychiatry Storybank. We included interviews of people who (a) lived through multiple psychotic episodes, and (b) spontaneously addressed traumatic experiences in a low-structured interview. Storyline analysis was performed to gain insight into the meaning-making of trauma within their self-stories. Psychosocial conceptualizations of narrative identity were used to inform the analysis. A data-validation session with four experts-by-experience was organized to check and improve the quality of our analysis.

Results

We identified four different story types: (1) Psychiatry as the wrong setting to find meaning; (2) The ongoing struggle to get trauma-therapy; (3) Exposure to trauma as a threat to a stable life, and (4) Disclosure as the key to resolving alienation. Each story type comprises a different plot, meaning of trauma withing the self-story, (lack of) integration and barriers and facilitators in the meaning-making process. Overall, barriers in the meaning-making process were mostly situated within mental healthcare and stigma-related. People felt particularly hindered by pessimistic ideas on their capacity to develop self-insight and cope with distress, resulting in limited treatment options. Their process of adaptive meaning-making often started with supportive, non-judgmental relationships with individuals or communities that offered them the safety to disclose trauma and motivated them to engage in a process of self-inquiry and growth.

Conclusion

The outcomes illuminate the social context of the meaning-making challenges that people with psychosis face and illustrate the devastating influence of stigma. Our outcomes offer guidance to remove barriers to adaptive meaning-making in people with psychosis, and can help clinicians to attune to differences in the meaning-making of trauma.

Barriers to delivering trauma-focused interventions for people with psychosis and post-traumatic stress disorder: A qualitative study of health care professionals' views

OBJECTIVES

Trauma-focused interventions have been shown to be effective treatments for post-traumatic stress disorder (PTSD), and clinical guidelines support their use with people with psychosis. Despite this, they are used relatively infrequently in this population. We sought to explore UK health care professionals' perceptions of what impedes or facilitates the use of trauma-focused interventions among people with psychosis and PTSD.

DESIGN

A qualitative study using constructivist grounded theory methodology.

METHODS

We conducted semi-structured interviews with 18 health care professionals working within the commissioning and delivery of clinical services for people with psychosis.

RESULTS

Three inter-related barriers to the use of trauma-focused interventions were conceptualized: coherent understanding; structural support; and safe space.

CONCLUSIONS

Delivery of trauma-focused interventions within routine clinical practice may be supported by attention to the coherent integration of discussion of trauma into the clinical discourse of services; the processes, pathways, and organizational culture that facilitate access to treatment; and training that targets clinician confidence and skills.

Recovering Context in Psychiatry: What Contextual Analysis of Service Users' Narratives Can Teach About Recovery Support

Aim: Enhancement of recovery-oriented care in psychiatry requires insight into the personal meaning and context of recovery. The Psychiatry Story Bank is a narrative project, designed to meet this need, by collecting, sharing and studying the narratives of service-users in psychiatry. Our study was aimed at expanding insight into personal recovery through contextual analysis of these first-person narratives. Methods: We analyzed 25 narratives, as collected through research interviews. To capture the storied context on both a personal, interpersonal and ideological level we combined several forms of qualitative analysis. A total of 15 narrative characteristics were mapped and compared. Results: Through comparative analysis we identified four narratives genres in our sample: Lamentation (narratives about social loss), Reconstruction (narratives about the impact of psychosis), Accusation (narratives about injustice in care), and Travelogue (narratives about identity transformation). Each genre provides insight into context-bound difficulties and openings for recovery and recovery-support. Conclusion: A contextual approach to studying personal recovery offers insights that can help attune recovery support in psychiatry. Important clues for recovery support can be found in people's narrated core struggle and the associated desire to be recognized in a particular way. Our results also indicate that familiarity with different ways of understanding mental distress, can help people to express and reframe their struggles and desires in a helpful way, thereby facilitating recognition.

Therapist training in evidence-based interventions for mental health: A systematic review of training approaches and outcomes

A lack of effective therapist training is a major barrier to evidence-based intervention (EBI) delivery in the community. Systematic reviews published nearly a decade ago suggested that traditional EBI training leads to higher knowledge but not more EBI use, indicating that more work is needed to optimize EBI training and implementation. This systematic review synthesizes the training literature published since 2010 to evaluate how different training models (workshop, workshop with consultation, online training, train-the-trainer, and intensive training) affect therapists' knowledge, beliefs, and behaviors. Results and limitations for each approach are discussed. Findings show that training has advanced beyond provision of manuals and brief workshops; more intensive training models show promise for changing therapist behavior. However, methodological issues persist, limiting conclusions and pointing to important areas for future research.

Traumatic loss and psychosis - reconceptualising the role of trauma in psychosis

Literature suggests that the occurrence of psychological trauma (PT) from various negative life experiences beyond events mentioned in the DSM-criterion A, receives little to no attention when comorbid with psychosis. In fact, despite research indicating the intricate interplay between PT and psychosis, and the need for trauma-focused interventions (TFI), there continue to be mixed views on whether treating PT would worsen psychosis, with many practitioners hesitating to initiate treatment for this reason. This study, therefore, aimed to understand patient perspectives on the role of PT in psychosis and related treatment options. A qualitative exploratory approach was adopted using in-depth interviews with individuals experiencing psychosis. The Global Assessment of Functioning (GAF) scale was administered on a predetermined maximum variation sample resulting in two groups of participants- those with moderate-mild disability (GAF 54-80; n = 10) and those experiencing moderate-severe disability (GAF 41-57; n = 10). With the former group, a semi-structured interview schedule was used, while with the latter, owing to multiple symptoms and difficulty in cognitive processing, a structured interview schedule was used. Results from interpretative phenomenological analysis (IPA) indicated that traumatic loss was central to experienced PT, but received no attention; this often contributed to the psychotic experience and/or depression, through maintenance factors such as cognitive distortions and attenuated affective responses. Further, the experience of loss seems to be more consequential to trauma-related symptoms than the event itself. Participants opined strongly the need for TFI and the role of it in promoting recovery from psychosis.

Therapist rotation: a novel approach for implementation of trauma-focused treatment in post-traumatic stress disorder

Background: Trauma-focused treatments (TFTs) for patients with post-traumatic stress disorder (PTSD) are highly effective, yet underused by therapists.Objective: To describe a new way of implementing (adequate use of) TFTs, using a therapist rotation model in which one patient is treated by several therapists.Method: In this article, we will present two examples of working with therapist rotation teams in two treatment settings for TFT of PTSD patients. We explore the experiences with this model from both a therapist and a patient perspective.Results: Our findings were promising in that they suggested that this novel approach reduced the therapists' fear of providing TFT to PTSD patients, increased perceived readiness for TFT, and decreased avoidance behaviour within TFT sessions, possibly leading to better implementation of TFT. In addition, the therapeutic relationship as rated by patients was good, even by patients with insecure attachment styles.Conclusions: We suggest that therapist rotation is a promising novel approach to improve implementation of TFT for PTSD.

The Role of Trauma and Stressful Life Events among Individuals at Clinical High Risk for Psychosis: A Review

The experience of childhood trauma (CT) and stressful life events (SLEs) is associated with subsequent development of a variety of mental health conditions, including psychotic illness. Recent research identifying adolescents and young adults at clinical high risk (CHR) for psychosis allows for prospective evaluation of the impact of trauma and adverse life events on psychosis onset and other outcomes, addressing etiological questions that cannot be answered in studies of fully psychotic or non-clinical populations. This article provides a comprehensive review of the current emerging literature on trauma and adverse life events in the CHR population. Up to 80% of CHR youth endorse a lifetime history of childhood traumatic events and victimization (e.g., bullying). Several studies have shown that the experience of CT predicts psychosis onset among CHR individuals, while the literature on the influence of recent SLEs (e.g., death of a loved one) remains inconclusive. Multiple models have been proposed to explain the link between trauma and psychosis, including the stress-vulnerability and stress-sensitivity hypotheses, with emphases on both cognitive processes and neurobiological mechanisms (e.g., the hypothalamic-pituitary-adrenal axis). Despite the preponderance of CHR individuals who endorse either CT or SLEs, no clinical trials have been conducted evaluating interventions for trauma in CHR youth to date. Furthermore, the current process of formal identification and assessment of trauma, SLEs, and their impact on CHR youth is inconsistent in research and clinical practice. Recommendations for improving trauma assessment, treatment, and future research directions in the CHR field are provided.