Trauma informed care for young people with psychosis David Keane and Joanna Ward-Brown
Aims for today Overview of links between trauma and psychosis NICE guidelines Gaps in services Secondment at the trauma service Summary of trauma focused therapy (using a modular approach) Service implications Discussion points
Pertinent Information from Research 50 to 98 % of the patients with a psychotic disorder have been traumatized (Read, Os, Morrison, & Ross, 2005) As a result the prevalence of PTSD in people with psychosis ranges from 12-29% (general population 0.4-3.5%) (Achim et al 2011) Recent meta-analysis found that major adversities in childhood increase risk of psychosis by 33% (doseresponse relationship reported)(varese et al 2012)
Dose response effect Chance of psychosis + Negative prognosis Severity, frequency and duration traumatisation
Pertinent Information from Research Significant associations between all types of childhood adversity (except loss of parent) and symptoms of paranoia and auditory hallucinations
Pertinent Information from Research: Do specific traumas cause specific symptoms? N=7353 (Adult Psychiatric Morbidity Survey) Data corrected for other psychotic symptoms and hallucinations and Paranoia Childhood sexual abuse 8.9 2.78 Physical abuse 4.79 8.52 Brought up in institutional care 3.45 11.08 Bentall, Wickham, Shevlin, & Varese (2012) Network Name
Working with complexity The commonality of causes and presenting needs The high level of co-morbidity Missed opportunities to intervene appropriately at an early stage Lancashire Traumatic Stress Service
Working with complexity The Bermuda Triangle Trauma Psychosis Personality disorder Lancashire Traumatic Stress Service
Thorough assessment of the blocks to natural recovery Unresolved trauma The way in which I make sense of myself and the world My ability to manage emotions Lancashire Traumatic Stress Service
NICE guidelines Psychosis Assessing for PTSD 16-20 sessions of CBT-P Family interventions Art therapies
NICE guidelines PTSD Early Recognition of PTSD TF-CBT / EMDR regardless of the time that has elapsed since the trauma 8 12 sessions when the PTSD results from a single event. Extending beyond 12 sessions if several problems need to be worked on Trauma-focused treatment needs to be integrated into an overall plan of care. Consider devoting several sessions to establishing a trusting therapeutic relationship and emotional stabilisation before addressing the traumatic event.
Current approaches in EIS REACH Tier 1- case managers working with trauma and other difficulties-reports of not feeling confident/worried about asking Tier 3- working with trauma along with other difficulties but some therapists not feeling skilled enough to do trauma-focused approaches
Gaps in service- The secondment One therapist identified to do a year-long one day a week secondment at Lancashire Traumatic Stress Service (LTSS) Aims: To offer TF-CBT and EMDR within a modular approach to 2 EIS clients To disseminate learning back to EIS (all three tiers)
Learning from the Dutch approach Offering NICE compliant treatment for comorbid PTSD Just get on with it!
Rebecca and Harriet Early intervention clients Referred for trauma focused therapy Both ready and willing to process difficult life events/traumas Both had experiences of hearing voices Seen for weekly sessions (with some natural gaps) for a year each
Modular approach Module 1: Introduction, Assessment and Formulation (Ehlers and Clark model, EMDR case conceptualisation in supervision-van den Berg et al., 2013) Module 2: Pharmacological Treatment (including prazosin) Module 3: Safety, Stabilisation, Building Resources, Behavioural Activation and Education
Modular approach Module 4: Sleep and Nightmare Management using Imagery rehearsal therapy (IRT) Module 5: Focussing on the Trauma- TF-CBT and/or EMDR (three methods approach described in van den Berg et al., 2013) Module 6: Post trauma growth, relapse prevention and preparing for the future.
Outcome Measures Impact of Events Scale Revised (IES-R) Choice (Recovery questionnaire) Sessional rating scale (LTSS measure) PSYRATS Work and Social Adjustment Scale (WSAS), Basic Emotions Scale (BES) Regulation of Emotions Questionnaire (REQ2) Becks Depression Inventory (BDI) Becks Anxiety Inventory (BAI) Clinician Administered PTSD scale (CAPS) Dissociative Experiences Scale (DES) Sessional Pre and post
Outcomes- Measures Regular outcome measures seem feasible, we used sessional measures of recovery, and also about the impact of trauma. Pre-post therapy we also assessed level of ptsd, mood, the regulation of emotions, dissociation, social and occupational functioning. We found improvement across all areas, most improved area was symptoms of PTSD. Clients reported reduced sadness, anger and disgust and improvements in happiness, less difficulty in regulating their emotions.
Outcomes Returning to work/finishing college Less distress around voices/unusual experiences More hope for the future Significant drop in flashbacks, PTSD symptoms Improved sleep More positive beliefs (about self, others and the world)
Feedback (from clients) Mixed feelings about coming to therapy and working on trauma Setbacks Importance of relationship with therapist Pros and cons of TF-CBT and EMDR Usefulness of modular approach
So...the challenge was
Translating what we know already about TF-CBT and EMDR to this service user population
Translating the modular framework to EIS The modular work fits in well with the EIS tiered model Parts of early modules (Assessment, formulation, safety, stabilisation and resource building, behavioural activation, psychoeducation, sleep and nightmare work) could fit into tier 1 and tier 2 work CBT-T and EMDR fits into tier 3 Need for further training in EIS (case managers and therapists)
EIS In-Service training Using the trauma service modular framework as a guide (to add to what we already do) Translating this into day-to-day practice in EIS (tiered model)
Conclusions Very limited evidence so far, but early indications are: Approach seems feasible and acceptable to service users. The use of regular outcome measures may be possible. Improvement observed in PTSD symptoms, occupational and social functioning, recovery, mood and emotional regulation.
Future plans Trialling these approaches Gathering evidence in your day to day role Developing care pathways Staff training Potential research
Discussion points How can we ensure that asking about trauma is further embedded in EIS? Does phasic/modular treatment have a role in EIS? Which modules for which tier/staff group? How can we skill up the workforce to work with trauma? (given limited resources)
Thank you for listening