I wrote a couple of days ago about Marylene Cloitre & colleagues's recent research paper "Treatment for PTSD Related to Childhood Abuse: A Randomized Controlled Trial", and yesterday I explored three questions that had struck me on thinking about this work - about the applicability of this approach to other (non child abuse) sufferers from complex PTSD, about the overlap with treatments for borderline personality disorder, and about the relatively brief duration of Cloitre's 16 session intervention for people suffering from such difficult symptoms. 

In today's third and last post about Cloitre's work, I want to think a little more around three further questions that I was struck by - 4.) What is involved in her skills-training module (an adaptation of dialectical behaviour therapy) and are there lessons here for other patients?  5.)  Arntz talks about the "limited re-parenting" involved in his work.  Cloitre discusses attachment issues and the importance of the therapeutic alliance.  Are there lessons here?  6.)  Was Cloitre's trauma processing treatment component as good as it could have been e.g. comparing it with Ehlers & Clark's version of trauma-focused CBT? 

So firstly - 4.) What is involved in her skills-training module (an adaptation of dialectical behaviour therapy) and are there lessons here for other patients? In their recent research paper, the STAIR - skills training in affect & interpersonal regulation - component of the treatment is 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."  Marsha Linehan's 1993 book on dialectical behaviour therapy (DBT) "Cognitive-Behavioral Treatment of Borderline Personality Disorder" is specifically cited.  This is very broad brush.  From my point of view, there are a whole series of psychotherapy approaches for "affect & interpersonal regulation" (some examples include ACT, Emotion-Focused Therapy, Schema-Focused Therapy, DBT, and Compassionate Mind Training).  Particularly as one moves from research on the treatment of specific conditions to broader, less diagnosis-linked interventions, it becomes increasingly difficult to make strong evidence-based claims for one approach over another.  However DBT derived treatments are certainly worth looking at respectfully.

Moving on - 5.)  Arntz talks about the "limited re-parenting" involved in his work.  Cloitre discusses attachment issues and the importance of the therapeutic alliance.  Are there lessons here?  Fascinating territory.  I've written a good deal about attachment in this blog.  See, for example, "Attachment, compassion & relationships" and "Our life stories: needs, beliefs & behaviours".  Cloitre has published very interesting work in this area.  Papers include "Attachment organization, emotion regulation, and expectations of support in a clinical sample of women with childhood abuse histories" and "Therapeutic alliance, negative mood regulation, and treatment outcome in child abuse-related posttraumatic stress disorder".  The latter paper's abstract reads "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 - to self soothe better.  Sounds like attachment territory to me.

And lastly - 6.)  Was Cloitre's trauma processing treatment component as good as it could have been e.g. comparing it with Ehlers & Clark's version of trauma-focused CBT?  In their recent 2010 paper, Cloitre et al write "In this study, the exposure treatment followed the prolonged exposure protocol, with the following two modifications for the study population: 1) in vivo exposure to trauma stimuli was replaced with interpersonal skills practice, and 2) meaning analysis was introduced after the exposure in which abuse-related schemas embedded in the trauma narrative were identified and evaluated. Exposure included narratives of both childhood and adulthood traumas, reviewed in order of distress rating and importance to the participant".  They cite Foa et al's 2008 book "Effective treatments for PTSD".  Sounds good.  In their recent paper "Do all psychological treatments really work the same in posttraumatic stress disorder?", Anke Ehlers et al write about the "significant increases in effect sizes of trauma-focused cognitive behavior therapies over the past two decades".  Cloitre's approach looks good and evidence-based and - like all our work - can no doubt evolve further.  My hunch is that it could learn usefully from the Ehlers & Clark approach, but I suspect we're talking about only minor increases in effectiveness over what is clearly already an effective version of trauma-focused cognitive therapy.

Overall, Marylene Cloitre and colleagues' research is an admirable further step in improving therapy for adult survivors of child abuse and for complex PTSD.  I for one want to learn from their addition of affect & interpersonal skills training and from their emphasis on the importance of the therapeutic alliance in helping clients develop improved affect regulation.