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Arntz & Jacob's new book "Schema therapy in practice": links with trauma-focused CBT and Marylene Cloitre's work on complex PTSD

I've written a couple of recent blog posts - "Arntz & Jacob's new book 'Schema therapy in practice': some introductory comments" and "Arntz & Jacob's new book 'Schema therapy in practice': links with attachment theory and with therapies for self-compassion".  In today's post I want to look at ST's focus on "problematic emotions" and "childhood issues" and the potential cross-fertilization with trauma-focused cognitive therapy and Marylene Cloitre's work on child abuse. These are huge areas fully capable of having whole books written about them.  I want to briefly discuss three points here.  The first is when might one decide to do trauma-processing/emotion-processing work and when might one go with a more "feel the pain & do it anyway" acceptance & commitment therapy or behavioural activation or mindfulness style non-cathartic approach?  The second is, if one is using a mix of emotion-processing cathartic and behavioural/reappraisal/mindfulness style non-cathartic work, in what order should one do the different types of intervention?  And the third point is, when doing the trauma/emotion-processing work, is it likely to be best to use simple, direct exposure or should one use forms of rescripting?  As always established practice & expert opinion are interesting but, if there are relevant hard research results, let's base our therapeutic decisions more on the latter.  As has been repeatedly pointed out "The plural of anecdote is not data".

So the first question is when might one go for a more cathartic emotion/trauma-processing approach and when might one use a more non-cathartic style?  Well, of central relevance here is the research position on best treatment of posttraumatic stress disorder.  The National Institute for Health and Clinical Excellence published their evidence-based guideline on PTSD treatment in 2005.  A research review at the end of 2011 concluded "No new evidence was identified in these areas which would change the direction of current guideline recommendations."  And what does the guideline say?  Well it clearly states "All people with PTSD should be offered a course of trauma-focused psychological treatment."  The guideline is also very clear on what it does not recommend.  Under "Do not do" it states "Drug treatments for post-traumatic stress disorder should not be used as a routine first-line treatment for adults ... in preference to a trauma-focused psychological therapy" and it goes on to say "Non-trauma-focused interventions such as relaxation or nondirective therapy, that do not address traumatic memories, should not routinely be offered to people who present with post-traumatic stress disorder (PTSD) symptoms."  So there are strong arguments for taking a more emotion/trauma-processing approach for PTSD symptoms following single type I trauma - for a state of the art look at this area see the series of seven posts on "Memory-focused approaches ... for adults with PTSD" starting last April.  But what about more complex type II trauma?  The American Academy of Child & Adolescent Psychiatry comments "Researchers have identified two basic types of psychic trauma: one-episode or single-blow psychic trauma, which results from a single, sudden, and unexpected event such as a rape, a bad car accident, or a devastating tornado; and repeated trauma, which arises from long-standing, repeated events, such as sexual or physical abuse."  Should we using trauma-focused approaches for this type II trauma?  Well it certainly seems so, but Marylene Cloitre's work adds further fascinating & important information.

I wrote a series of three posts on Cloitre & colleagues' research starting with "Improving treatments for complex PTSD and for survivors of child abuse".  The abstract of her 2010 American Journal of Psychiatry paper - "Treatment for PTSD Related to Childhood Abuse: A Randomized Controlled Trial" - read "Objective: Posttraumatic stress disorder (PTSD) related to childhood abuse is associated with features of affect regulation and interpersonal disturbances that substantially contribute to impairment. Existing treatments do not address these problems or the difficulties they may pose in the exploration of trauma memories, an efficacious and frequently recommended approach to resolving PTSD. The authors evaluated the benefits and risks of a treatment combining an initial preparatory phase of skills training in affect and interpersonal regulation (STAIR) followed by exposure by comparing it against two control conditions: Supportive Counseling followed by Exposure (Support/Exposure) and skills training followed by Supportive Counseling (STAIR/Support). Method: Participants were women with PTSD related to childhood abuse (N=104) who were randomly assigned to the STAIR/Exposure condition, Support/Exposure condition (exposure comparator), or STAIR/Support condition (skills comparator) and assessed at posttreatment, 3 months, and 6 months. Results: The STAIR/Exposure group was more likely to achieve sustained and full PTSD remission relative to the exposure comparator, while the skills comparator condition fell in the middle (27% versus 13% versus 0%). STAIR/Exposure produced greater improvements in emotion regulation than the exposure comparator and greater improvements in interpersonal problems than both conditions. The STAIR/Exposure dropout rate was lower than the rate for the exposure comparator and similar to the rate for the skills comparator. There were significantly lower session-to-session PTSD symptoms during the exposure phase in the STAIR/Exposure condition than in the Support/Exposure condition. STAIR/Exposure was associated with fewer cases of PTSD worsening relative to both of the other two conditions. Conclusions: For a PTSD population with chronic and early-life trauma, a phase-based skills-to-exposure treatment was associated with greater benefits and fewer adverse effects than treatments that excluded either skills training or exposure".

As the associated free full text editorial by Richard Bryant - "The Complexity of Complex PTSD" - pointed out "Trauma-focused therapies, and cognitive-behavioral therapy (CBT) in particular, have become the treatment of choice for posttraumatic stress disorder (PTSD) over the past two decades. A cautionary note about the general applicability of CBT has been that it may not adequately address the nature and breadth of psychological difficulties experienced by patients with more emotionally complex PTSD secondary to childhood adversity. In the article by Cloitre et al. in this issue of the Journal, this question is addressed with a controlled trial that compares the relative efficacies of standard CBT with a version of CBT that is augmented by skills training that prepares the patient for the emotional reactions associated with CBT. This trial is predicated on the premise that childhood abuse can lead to PTSD that is complicated by impairments in regulating emotion, which can compromise the ability to cope with the distress elicited by trauma-focused CBT. By training patients in emotion regulation, this therapy aims to compensate for the purported deficits in patients with more complex PTSD. The importance of this study lies in its finding that augmented CBT led to greater treatment gains and fewer dropouts from therapy in these patients than standard CBT ... The finding by Cloitre et al. that patients characterized by emotion regulation problems could be retained in therapy and provided with efficacious exposure-based therapy highlights the need to recognize these patients in order to provide them with a targeted intervention that is different from existing formats of CBT ... The novelty of the Cloitre et al. study is that it advances current treatments beyond their current capacity and extends this evidence-based intervention to a wider range of patients."

It's worth pointing out that Cloitre's staged treatment approach for complex PTSD might best be used where there are symptoms of significant emotion dysregulation & interpersonal difficulty.  This is certainly true for some people who have experienced prolonged child abuse, but not all ... and it's also true for some people who have experienced prolonged abuse as adults (for example some survivors of torture or domestic violence).  It's also worth noting that STAIR (skills training in affect and interpersonal regulation) was described as follows: "The skills training interventions are adapted from dialectical behavior therapy. The first four skills sessions concern emotion regulation and focus on identifying and labeling feelings, emotion management, distress tolerance, and acceptance of feelings and experiencing positive emotions. The next four sessions concern interpersonal problems and focus on exploration and revision of maladaptive schemas, effective assertiveness, awareness of social context, and flexibility in interpersonal expectations and behaviors."  And finally in this description of Cloitre's research, I would also point out that the abstract of a linked paper - "Therapeutic alliance, negative mood regulation, and treatment outcome in child abuse-related posttraumatic stress disorder" - read "This study examined the related contributions of the therapeutic alliance and negative mood regulation to the outcome of a 2-phase treatment for childhood abuse-related posttraumatic stress disorder (PTSD). Phase 1 focused on stabilization and preparatory skills building, whereas Phase 2 was comprised primarily of imaginal exposure to traumatic memories. Hierarchical regression analyses indicated the strength of the therapeutic alliance established early in treatment reliably predicted improvement in PTSD symptoms at posttreatment. Furthermore, this relationship was mediated by participants' improved capacity to regulate negative mood states in the context of Phase 2 exposure therapy. In the treatment of childhood abuse-related PTSD, the therapeutic alliance and the mediating influence of emotion regulation capacity appear to have significant roles in successful outcome". So there are indications that a strong therapeutic alliance is helpful through improving patients' capacity to regulate negative mood through self soothing better. Sounds like attachment territory to me.

As Cloitre & colleagues' paper last year - "Treatment of complex PTSD: results of the ISTSS expert clinician survey on best practices" - emphasises "Experts agreed on several aspects of treatment, with 84% endorsing a phase-based or sequenced therapy as the most appropriate treatment approach with interventions tailored to specific symptom sets. First-line interventions matched to specific symptoms included emotion regulation strategies, narration of trauma memory, cognitive restructuring, anxiety and stress management, and interpersonal skills. Meditation and mindfulness interventions were frequently identified as an effective second-line approach for emotional, attentional, and behavioral (e.g., aggression) disturbances. Agreement was not obtained on either the expected course of improvement or on duration of treatment. The survey results provide a strong rationale for conducting research focusing on the relative merits of traditional trauma-focused therapies and sequenced multicomponent approaches applied to different patient populations with a range of symptom profiles."

At the start of this rather long post, I said I wanted to discuss three points. The first is when might one decide to do trauma-processing/emotion-processing work and when might one go with a more "feel the pain & do it anyway" acceptance & commitment therapy or behavioural activation or mindfulness style non-cathartic approach.  It seems likely that when there is an underlying background of simple or complex trauma, it may well be more effective to incorporate trauma/emotion-processing components into the treatment.  The second point is, if one is using a mix of emotion-processing cathartic and behavioural/reappraisal/mindfulness style non-cathartic work, in what order should one do the different types of intervention?  Here it looks as though the more problems the client has with emotion regulation & interpersonal difficulties, the more one might want to teach skills relevant to these areas & build the therapeutic alliance before embarking on any direct trauma work.  And the third point I queried is, when doing the trauma/emotion-processing work, is it likely to be best to use simple, direct exposure or should one use forms of rescripting?  I'll leave this last question to the next post - see "Working with traumatic memories: KISS (keep it simple, stupid) and the virtues of straightforward prolonged exposure."

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