Integrated Trauma-Focused Cognitive-Behavioural Therapy for Post-traumatic Stress and Psychotic Symptoms: A Case-Series Study Using Imaginal Reprocessing Strategies

Abstract

Despite high rates of trauma in individuals with psychotic symptoms, post-traumatic stress symptoms are frequently overlooked in clinical practice. There is also reluctance to treat post-traumatic symptoms in case the therapeutic procedure of reprocessing the trauma exacerbates psychotic symptoms. Recent evidence demonstrates that it is safe to use reprocessing strategies in this population. However, most published studies have been based on treating post-traumatic symptoms in isolation from psychotic symptoms. The aims of the current case series were to assess the acceptability, feasibility, and preliminary effectiveness of integrating cognitive-behavioural approaches for post-traumatic stress and psychotic symptoms into a single protocol. Nine participants reporting distressing psychotic and post-traumatic symptoms were recruited from a specialist psychological therapies service for psychosis. Clients were assessed at five time points (baseline, pre, mid, end of therapy, and at 6+ months of follow-up) by an independent assessor on measures of current symptoms of psychosis, post-traumatic stress, emotional problems, and well-being. Therapy was formulation based and individualised, depending on presenting symptoms and trauma type. It consisted of five broad, flexible phases, and included imaginal reprocessing strategies (reliving and/or rescripting). The intervention was well received, with positive post-therapy feedback and satisfaction ratings. Unusually for this population, no-one dropped out of therapy. Post therapy, all but one (88% of participants) achieved a reliable improvement compared to pre-therapy on at least one outcome measure: post-traumatic symptoms (63%), voices (25%), delusions (50%), depression (50%), anxiety (36%), and well-being (40%). Follow-up assessments were completed by 78% (n = 7) of whom 86% (n = 6) maintained at least one reliable improvement. Rates of improvements following therapy (average of 44% across measures post therapy; 32% at follow-up) were over twice those found during the waiting list period (19%). No participant indicated a reliable worsening of any symptoms during or after therapy. The study shows that an integrative therapy incorporating reprocessing strategies was an acceptable and feasible intervention for this small sample, with promising effectiveness. A randomised controlled trial is warranted to test the efficacy of the intervention for this population.

Imagery rescripting for the treatment of trauma in voice hearers: a case series

“…Although the precision of this finding is small (given the small sample size), it may be attributable to the type of trauma therapy administered. Keen et al (2017) reported a high drop-out rate (35.6%) in their case-series (n = 14) of prolonged exposure in veterans with PTSD and psychosis. Their qualitative analysis showed that drop-out was mostly related to fear about their ability to manage distress associated with the reliving of the hot part of traumatic memories during PE.…”

“…First, exposure-based interventions may not be tolerated at a level sufficient to produce effects on voice hearing experiences. Of note, Keen et al (2017) link the high drop-out rates seen when using prolonged exposure with psychosis to fear and avoidance of the reliving of traumatic memories. Second, exposure-based interventions may not work on the mechanisms which underlie the link between trauma symptoms and hearing voices [see Hardy (2017) for a discussion of a number of possible underlying mechanisms].…”

Imagery rescripting in non-clinical paranoia: a pilot study of the impact on key cognitive and affective processes

“…A recent review of the impact of trauma interventions on psychosis found small effects on positive symptoms that were not maintained at follow-up, and small effects on trauma symptoms that were only significant at follow-up (Brand et al, 2018). A case series of imagery rehearsal for nightmares in people with psychosis also found reductions in nightmare-related distress but not psychosis (Sheaves et al, 2015), and a clinical case series of imaginal reprocessing based on individualized formulation of people's trauma and psychosis showed promising results, although more conclusively in measures of trauma than psychosis (Keen et al, 2017).…”

A Systematic Review on Psychological and Biological Mediators Between Adversity and Psychosis: Potential Targets for Treatment

“…17 . In some cases, dissociative symptoms may be very disruptive and prevent access to the other targets; in this case they can be prioritized and targeted using sensory grounding techniques to help the individual reliably regain contact with present external stimuli 97,98 .…”