A Mixed Methods Evaluation of a Stabilisation Course for Adults with Post-Traumatic Stress Disorder (PTSD) in IAPT

Full text

A Mixed Methods Evaluation of a Stabilisation Course for
Adults with Post-Traumatic Stress Disorder (PTSD) in IAPT
Journal:
Behavioural and Cognitive Psychotherapy
Manuscript ID
Draft
Manuscript Type:
Main
Keywords:
PTSD, Stabilisation, Group Interventions, CBT, IAPT
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Running Head: PTSD STABILISATION COURSE EVAULATION 1
Nearly a third (31.4%) of the UK general population reports a traumatic event in their
lifetime, 4.4% of whom meet the screening criteria for PTSD (McManus et al., 2016). The
NICE guidelines recommends that individuals with clinically relevant symptoms of PTSD
should be offered trauma-focused Cognitive Behavioural Therapy (TF-CBT), one month after
the traumatic event (NICE, 2018). TF-CBT protocols drawing on the Ehlers and Clark (2000)
model describe three therapeutic aims: trauma memory elaboration and integration, the
modification of trauma appraisals and the reduction of unhelpful cognitive and behavioural
strategies (Ehlers et al., 2005). The effectiveness and safety of TF-CBT for individuals with
PTSD has been supported by vast research, with benefits present for those exposed to varying
traumatic experiences (Kar, 2011). However, not everyone responds to or can tolerate TF-
CBT, in particular, those who experience high levels of emotional instability (Schottenbauer
et al., 2008). This is a common treatment barrier amongst those with Complex-PTSD (C-
PTSD), who may also experience interpersonal difficulties, dissociation, strong feelings of
shame or guilt and an adversely impacted belief-system (Cloitre et al., 2013). Although
individuals with PTSD may also experience some of these additional C-PTSD symptoms,
they are usually predicted by traumatic events that are repeated, prolonged and interpersonal
in nature, such as child abuse or torture (Herman, 1992).
To overcome emotional instability as a barrier of TF-CBT, a phased-approach to
treatment has been recommended (Cloitre et al., 2012). The first phase of ‘stabilisation’, aims
to reduce the intensity of emotions and illicit a sense of safety through teaching techniques to
manage re-experiencing symptoms (nightmares and flashbacks). Psycho-education is also
incorporated, whereby individuals are taught to recognise “symptoms instead of memories”
and to understand their etiological underpinnings (Fisher, 1999, p. 3). Following stabilisation,
the traditional components of TF-CBT are delivered, including re-processing. Finally, phase
three or ‘re-integration’ aims to support individuals to maintain their therapeutic gains and to
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PTSD STABILISATION COURSE EVALUATION 2
move forward from the trauma. It is important to note that although the phases of intervention
are successive, there is often a degree of alternation between phases, especially during re-
processing where stabilisation techniques may be required to progress (Cloitre et al., 2012).
The evidence base for stabilisation as a method for improving PTSD symptoms or
aiding later phases of intervention protocols is mixed and is a matter of current debate. In
support of stabilisation, it has been found that the emotional regulation achieved through the
use of stabilisation techniques is predictive of subsequent symptom improvement during re-
processing for those with C-PTSD. However, PTSD symptoms did not improve through
stabilisation alone (Cloitre et al., 2002; 2010). As a stand-alone, one-to-one intervention,
stabilisation has been found to reduce PTSD symptoms amongst a Southeast-Asian sample,
with some participants entering remission (Eichfeld et al., 2019; Mattheß et al., 2019). On the
other hand, stabilisation’s role as the first phase of TF-CBT has been highly questioned given
a lack of compelling evidence. Across studies reviewed, Bicanic and colleagues (2015) found
that TF-CBT was effective with or without a preceding stabilisation phase. Furthermore, the
methodological rigor of studies in support of a phased-approach has been subject to criticism,
whilst TF-CBT has been shown to confer few intolerable risks to patients (De Jongh et al.,
2016). Taking this into account, the authors concluded that the clinical guidance of using
stabilisation may in fact delay individuals from receiving evidenced-based interventions.
Despite mixed-evidence, stabilisation interventions have been re-packaged into group
formats. As described by Robertson and colleagues (2013), the Traumatic Stress Clinic
designed a time-limited stabilisation group intervention for refugees and asylum seekers,
covering psycho-education and a variety of techniques. Although its evaluation has not been
published, it has severed as a useful protocol for further studies. For example, Readings
(2016) reported that PTSD symptoms reliably improved for nine patients who attended a
group stabilisation course as part of a case-series. Furthermore, the effectiveness and
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PTSD STABILISATION COURSE EVALUATION 3
feasibility of a 20-week stabilisation group, drawing on CBT, has been indicated for
individuals with C-PTSD by one pilot-study, in which 64% of participants no longer met
diagnostic criteria post-treatment (Dorrepaal et al., 2010). Contrary to this, a more recent
study did not observe a significant reduction of PTSD symptoms amongst a sample of
individuals with C-PTSD that attended a similar short-term stabilisation group (Beldman et
al., 2017). Taken together, the evidence base of group stabilisation appears limited. PTSD is
treated with high-intensity interventions, such as TF-CBT, within IAPT services. However,
long wait-lists for treatment are a concern across England. Whilst left untreated, the
symptoms of PTSD can become chronic; having detrimental effects on physical health and
functioning. Furthermore, it has become increasingly more common for C-PTSD
presentations to be addressed in IAPT that require practitioner training and greater input,
including stabilisation (Murray, 2017). Acknowledging this, some IAPT services offer group
courses covering the therapeutic components of PTSD stabilisation, for example, the four-
session course delivered by Milton Keynes IAPT as described by Helm and Gercs (2017).
The course was found to confer a reliable improvement in PTSD symptoms for 46% of the
sample (N = 24). Besides these unpublished findings, there are no effectiveness or feasibility
evaluations of group PTSD stabilisation interventions delivered within an IAPT setting. The
current study aims to achieve this, drawing on a mixed-methods design.
Method
Design
To explore the feasibility and effectiveness of the group-delivered PTSD stabilisation
intervention, the current study employed a mixed-methods design with several sources of
quantitative and qualitative data. Given that the aim of the study was to determine feasibility
and effectiveness where no previous studies have done so, the results of the study are to be
considered preliminary and for this reason, no control sample was obtained. The study was
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brought to the Trust’s local R&D Committee and was approved as a service evaluation not
requiring full NHS ethical approval.
Participants
The sample of the course was comprised of individuals on the waitlist for TF-CBT at Barnet
IAPT. Inclusion criteria were as follows: an ICD-11 (WHO, 2019) informed problem
descriptor of PTSD or C-PTSD assigned at triage, ≥ 18 years, proficient in English, IES-R
score ≥ 33 with indications of re-living symptoms or emotional instability and capable of
giving informed consent. Participants were screened by a clinician to confirm that they met
the inclusion criteria. If an individual agreed to attend the course and met eligibility criteria,
they were sent an invite letter with an information sheet (N = 26). Of those who completed
the course (N = 22), eleven participants took part in a semi-structured interview. To explore
staff perspectives of the course, six members of staff took part in a focus group. This included
both facilitators (CLC & AF), the clinical lead and course supervisor (LV) and three CBT
therapists who had patients that attended the course.
Procedure
Following screening, participants provided pre-intervention outcome measures. The same set
of measures was completed after each session and stored on the PCMIS case-management
system. Feedback forms were provided at the last session. Participants were invited for a
post-intervention assessment within one month of the course, in which outcome measures
were collected again and semi-structured interviews were conducted upon receiving
participant consent.
Intervention
The stabilisation course was delivered in groups of 4-8 participants and consisted of four
sessions on a weekly basis. Each session lasted two hours with a 20-minute break. A 30-
minute debrief ensuing each session was offered to individuals that had concerns regarding
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PTSD STABILISATION COURSE EVALUATION 5
their ability to keep themself safe. The course was delivered by a trainee clinical psychologist
(CLC) and a BABCP accredited CBT therapist (AF). Both facilitators received supervision
by the clinical lead of the service (LV).
The content of the course was adapted from pre-existing stabilisation protocols
derived from CBT and Compassion-focused therapy, whilst its theoretical basis was largely
informed by Fisher (1999). Session one covered trauma psycho-education and safety
planning. The second session introduced self-compassion techniques, soothing strategies and
attention-focus training. This was followed by grounding techniques, distraction and
distancing strategies, self-care and sleep management (sleep hygiene and handling
nightmares) in session three. In the final session, safety plans were reviewed, the techniques
were recapped and goals were set for one-to-one therapy. Each session was supplemented by
PowerPoint slides and worksheets. A self-help booklet covering content from all sessions was
provided. During sessions, the techniques were practiced by participants. Between sessions,
participants were encouraged to implement the techniques and feedback their experiences at
the beginning of the next session. It is important to note that the participants were instructed
not to discuss their traumas in depth, to prevent the occurrence of flashbacks and dissociation
in-session. Instead, the emphasis was placed on psycho-education and the practice of
techniques. A full copy of the intervention for future research or clinical purposes can be
obtained through contacting the corresponding author (CLC).
Measures
To determine the effectiveness and satisfaction of the course, several questionnaires were
administered.
Impact of Events Scale-Revised (IES-R; Weiss & Marmar, 1996) is a self-report
measure, routinely used in IAPT services, of subjective distress associated with 22-items that
reflect the symptoms of PTSD as determined by the DSM-IV. Respondents are required to
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PTSD STABILISATION COURSE EVALUATION 6
state a specific stressful life event, which relates to the symptoms they are experiencing over
the last week. On each item, respondents use a five-point scale, ranging from 0 (“not at all”)
to 4 (“extremely”), to indicate the extent to which they are distressed by the symptom. A total
score can range from 0 to 88, with a score ≥ 33 indicative of clinically relevant symptoms of
PTSD. The IES-R also includes the subscales of Intrusion, Avoidance and Hyper-arousal.
Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001) is used to measure
depression symptom severity as part of research projects and in clinical practice. The nine
self-report items are derived from the DSM-IV and can produce a total score ranging from 0
to 27.Response options are designed to indicate how much an individual has been bothered
by symptoms over the past two weeks. Options include 0 (“not at all”), 1 (“several days”), 2
(“more than half the days”) and 3 (“nearly every day”). A total score ≥ 10 indicates clinically
relevant symptoms of depression.
Generalized Anxiety Disorder-7 (GAD-7; Spitzer et al., 2006) is comprised of seven
items to measure the severity of anxiety symptoms in line with the DSM-IV. Like the PHQ, it
uses a response scale ranging from 0 (“not at all”) to 3 (“nearly every day”), producing a
possible total score between 0 and 21. A total score ≥ 8 indicates clinically relevant
symptoms of anxiety.
Work and Social Adjustment Scale (WSAS; Mundt et al., 2002) is a five-item self-
report measure of functional impairment across the domains of occupation, home
management, social and private leisure activities and relationships. A respondent is required
to rate each domain in terms of how much it is effected by their problem on a scale ranging
from 0 (“not at all”) to 8 (“very severely”). A higher score indicates greater functional
impairment, with a possible total score of 40 or 32 possible (if occupation was marked as
“n/a”).
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PTSD STABILISATION COURSE EVALUATION 7
Course Feedback Questionnaire was produced to ascertain participant satisfaction
across 11 items and three open-ended questions. The items were based on the Patient
Experience Questionnaire (PEQ; NCCMH, 2018) or were designed specifically to collect
additional data, which could be used to explain the other findings of the study. Respondents
used a five-point scale to reflect how much they agreed with varying statements about the
course (“Strongly Disagree”, “Disagree”, “Neutral”, “Agree” and “Strongly Agree”).
Analysis
The outcome measures (and IES-R sub-measures) were analysed using SPSS-22 to compare
the sample means at pre- and post-intervention. Parametric assumptions of normality were
violated on multiple variables and for this reason, mean differences were analysed using
Wilcoxon matched-pairs tests. The results of the feedback questionnaire were calculated as
frequencies.
The semi-structured interviews with the participants and the focus group of
practitioners were recorded and transcribed. The transcripts were then read on multiple
occasions to acquire an overall impression of the data. Following this, thematic analysis as
described by Braun and Clarke (2006) was applied to the transcripts in order to generate
themes relating to the barriers and facilitators of the courses ability to meet patient goals from
the perspective of practitioners and patients. Although the analysis was conducted by the first
author (CLC), the rest of the research team also had a role in discussing and finalising the
themes identified.
Results
Sample Characteristics
The characteristics of the sample are presented in Table 1. Four participants (15.38%)
dropped out of the course: two reported bereavement, one was unwell and the other could not
commit to the schedule.
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PTSD STABILISATION COURSE EVALUATION 8
[Table 1]
Outcome Measures
Descriptive and inferential statistics for the outcome measures at pre- and post-intervention
are presented in Table 2. Statistically significant improvements were observed in IES-R
(including on all sub-measures) and GAD-7 scores.
[Table 2]
Course Feedback
As shown by Figure 1, there were high levels of satisfaction regarding the course, with 16
attendees (72.7%) reporting that they would strongly recommend the course to others, whilst
21 (93.5%) agreed or strongly agreed that their needs were met. It is also important to note
that 19 (86.4%) of the participants agreed or strongly that they had learned strategies to
manage their symptoms effectively, whilst one strongly disagreed, and 21 (95.5%) agreed or
strongly agreed that the course had improved their understanding of trauma and its
symptoms. A minority of patients disagreed or strongly disagreed that it was useful to hear
the experiences of others in the group (9%) and that the number of sessions was adequate
(27.2%).
[Figure 1]
Participant Interviews
The following themes regarding the barriers and facilitators of patient goal attainment during
the course were identified. These are discussed below alongside quotations.
Facilitators
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PTSD STABILISATION COURSE EVALUATION 9
Psycho-education. Every participant interviewed reported that receiving psycho-
education about trauma and the symptoms of PTSD helped them to meet their treatment
goals:
“…We were told about the brain, the effects of trauma and the filing cabinet
metaphor that shows how the brain deals with it. I found that very helpful because
instead of me feeling like I was alone with all of this and that there was something
really wrong with my head. I was able to see that actually ‘no it is just my brain has
not been able to process this’…”
The above participant highlighted the use of metaphors to support their understanding of the
psycho-education content. Other participants also conveyed that through attending the
course, they were now able to normalise their symptoms and demonstrate self-compassion:
“Those four weeks did help me to think: ‘it’s okay that you’re not coping at the
moment, but give yourself time’. I learned I am terrible at self-criticism…so now, I
say to myself ‘be kind to yourself…self-compassion was a big theme of the four
weeks”
“I feel a sort of acceptance for the way I am - what I am experiencing is quite normal
given what has happened…I suppose it is just sort of that a lot of the things that I did
not understand about myself, I understand now”
Group Processes. A majority of participants valued the group format of the
intervention, with many stating that group processes promoted the attainment of their goals
and reinforced their attendance.
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PTSD STABILISATION COURSE EVALUATION 10
“Being with the group made me feel supported, acknowledged, valued, accepted, and
understood”
One participant reflected on the diversity of the group she attended, which disproved some of
her post-trauma appraisals through identifying with others:
“…There were a lot of different people, of all ages and genders. One lady there
spoke to us about her past and how it affected her…I learned it can happen to anyone.
Just understanding what it was and that I am not alone really helped me”
Some participants found that a sense of hope was installed through hearing about the
progression of other participants:
“One man explained that he had moved on from his experience. It was real and
helpful, it wasn’t just theory. I saw that people could benefit from this therapy”
It was also commonly reported that collaborative therapeutic relationships developed between
the participants, rather than just with the facilitators. In one case, the relationships continued
beyond the conclusion of the course:
“I felt comfortable with the other attendees of the course, they shared their
experiences and it helped us to bond. We went on to set up a WhatsApp group and
exchanged contact details”
The facilitators. There was a consensus that the content of the course was delivered
effectively and that the facilitators possessed personal qualities, which aided the therapeutic
process:
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PTSD STABILISATION COURSE EVALUATION 11
“What impressed me the most was the facilitators, their empathy and that they didn’t
rush, they explained everything in detail, slowly...They always asked if anyone had
any questions and if they did, they were allowed to stay behind”
In particular, many of the participants valued the ‘personal touch’ of the facilitators and
found them to be relatable:
“They explained it very well and they gave examples, even their own examples so it
felt that even the facilitators had their own personal struggles, which again helped me
to realise that we are all human beings at the end of the day”
It is also important to note that many of the participants felt anxious about their attendance at
first; although the majority agreed that the qualities of the facilitators enabled them to
develop trust:
“…it was relaxed as something like that can be and I think obviously the course
facilitators were very nice. I think people felt able to say what they wanted to. But
obviously you don't know anyone so it takes a while to build up that sort of trust with
people in the room”
Stabilisation Techniques. The techniques were perceived as helpful in meeting
therapeutic goals by all of the participants. The five-senses grounding exercise appeared to be
the most favoured technique across all participants. One participant gave an account of its use
when they encountered a trauma reminder:
“I could feel my heart was beating really fast and then I remembered and said to
myself: ‘right go back to the group sessions, remember the five senses’…If I had not
attended these sessions I would not have the tools and ways to react”
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PTSD STABILISATION COURSE EVALUATION 12
It was apparent that the participants valued the opportunity to practice techniques in-session,
given the interactive nature of the course:
“…it was practical and we tried them out [the techniques] in the session. I would
have liked more of that”
Many participants appreciated the techniques since they enabled them to manage their
symptoms whilst they were on the wait-list for CBT:
“…They helped to ‘tide us over’ so you like, for the long wait, which was obviously
not your fault but it’s a problem for us. It’s quite a while to wait for 1-1 therapy, but
since the course, I’m using the techniques to fill the time, it’s certainly been helpful”
Supplementary Materials. Eight participants stated that the supplementary materials
of the course (the PowerPoint, booklet and worksheets) helped them to meet their goals
through assisting the learning process:
“The PowerPoint was very useful because it helped me understand everything more,
as did the hand out”
Some participants reported keeping the materials to hand so that they can serve as reminders
when encountering difficulties:
“I like the materials, in fact I have them in my bag. I always carry them around with
me. If something is bothering me, I can think ‘what did they say about that’, and I can
review it and try a technique out”
Barriers
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PTSD STABILISATION COURSE EVALUATION 13
Symptom Interference. A significant proportion of patients stated that their symptoms
were present during the sessions, which made it difficult to engage.
“…initially it was difficult to absorb it all and fully engage with it, because I came in
very tense. At times when I was sitting down my muscles were tightening up which
made absorbing all that information very difficult for me…I think also mentally there
was a mental block to absorbing it”
Aside from anxiety symptoms, some participants found that aspects of the course triggered
flashbacks:
“The course reminded me of it all again. Although it teaches me of how to manage
this, it brought it all back during the session”
Session Limitations. Aside from one, the participants agreed that there were not
enough sessions to meet their treatment goals. Four participants suggested that 12 sessions
would be needed:
“I think it just wasn't long enough…when something has such an impact on an
individual’s life, four weeks really is not enough…I think if we were to get to
everything we would need, twelve sessions at least.”
Stigma and Shame. The participants reported observing or experiencing the impact of
stigma on their willingness to discuss their experiences.
“…A lot of people hide their feelings in the sessions because they do not want to be
judged and they do not want to be thought of as crazy or misunderstood. The way
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PTSD STABILISATION COURSE EVALUATION 14
society is, it is quite judgemental, and I think some are carrying shame for having
these feelings and thoughts”
A suggestion was made to run courses for individuals that have experienced similar traumas,
to overcome shame:
“My suggestion is that if people in the group have had the same traumatic
experience, then it would be better for them to be together…I think this would give
people greater confidence to speak”
Practical Issues. Finally, five participants raised their concerns about practical issues
that impeded their therapeutic goals. This included the facilities, the setting and the font-size
of the materials.
“I think that tea and coffee facilities could have been a bit better. That’s just by the
by. That is just the NHS for you”
“Maybe a room with more light, more natural light or space…natural light makes me
more comfortable”
Practitioner Focus Group
The perspectives of the practitioners who attended the focus group reiterated all of the above
barriers and facilitators. The following additional themes were identified from the focus
group.
Facilitators
Risk Management. All of the participants agreed that the course helped to manage
patient risk, either during the course or when one-to-one therapy commenced. A facilitator
stated:
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“…It meant that we could routinely assess risk and establish safety plans, prior to
them starting one-to-one therapy”
Practitioners who had patients attend the course perceived their patients risk as having
reduced by the time one-to-one therapy commenced.
Workload Reduction. Practitioners held the consensus that the course reduced the
number of sessions required at one-to-one therapy, given that stabilisation had already been
covered:
“Because they’ve already done stabilisation and grounding, then we were able to get
straight to re-processing, sooner rather than later, saving me and the patient a
number of sessions”
“…my patient had a greater understanding of trauma, it made them more prepared
and I got the sense that they knew what to expect from CBT at that point…all of this
made them seem more forthcoming in our sessions and more committed”
Barriers
Team Referrals. Some of the practitioners believed that some patients did not have
the opportunity to attend the course because the team as a whole was not forthcoming in
making referrals:
“There were few referrals from the team…perhaps there was a lack of awareness, a
lack of knowledge about stabilisation. It was discussed in team meetings but perhaps
they were not confident in referring”
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Lack of Suitability. Two practitioners felt that their patient’s difficulties were too
complex for the course given their trauma history or current life stressors and doubted how
much they benefited:
“My client had lots going on, like having to attend the Home Office. They didn’t see
the course as a priority and maybe not even relevant at that time. There’s too much
stress going on aside from the trauma for them”
“…After the four sessions, it was still hard for him to make the necessary
connections, I put this down to complexity, he needed more of these sessions”
Symptom Relapse. All four practitioners who had patients attend the course
commented on the fact that their patients scores increased between finishing the course and
starting one-to-one therapy:
“…during the gap her scores got worse…they did initially come down but for
whatever reason, things got bad again, I found myself having to backtrack “
One practitioner suggested that this was the result of the patients discontinued use of the
techniques:
“…they slipped back into their old habits – they stopped using the techniques whilst
waiting for one-to-one therapy…it came down to their beliefs, they felt it wasn’t
addressing the underlying problem quick enough”
Discussion
The current study evaluated the effectiveness and feasibility of a stabilisation course for
adults with PTSD in a primary-care setting, using a mixed-methods design. The findings
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discussed provide preliminary support for the interventions use within IAPT services, which
to our knowledge, has not been previously researched.
A high proportion of patients (85%) completed all four sessions; exceeding the
expectation of a high-dropout rate that is commonplace for group interventions (Whitfield,
2010). Amongst those who completed the course, a statistically reliable reduction in PTSD
and anxiety symptoms was observed. However, there was no reliable change in depression
symptoms and functional impairment. Participants were highly satisfied with the course as
reflected in the results of the feedback questionnaire. Considering feasibility, several barriers
and facilitators of the courses delivery were identified. These were consistent from both the
perspective of the participants and the course facilitators.
The current study was naturalistic in design with no control group and therefore, its
promising results must be interpreted with caution. Nevertheless, the results mirror the
findings of Dorrepaal and colleagues (2010), who also observed a reduction in PTSD
symptoms through the delivery of a stabilisation course, albeit over 20 sessions and solely for
those with C-PTSD. Despite a more compact design, similar results were attained, suggesting
that the intervention may be cost-effective for IAPT services. It is important to note that
although PTSD symptoms improved for the sample as a whole, only two patients entered
recovery on the IES-R. This reinforces the claim that although stabilisation is beneficial for
the latter stages of a phased approach to TF-CBT, it cannot be viewed as a standalone
intervention that replaces the core component of re-processing (Bicanic et al., 2015). This
outlook may also explain why low mood symptoms and functional impairment did not
improve for the sample, since without re-processing, PTSD symptoms may have continued to
maintain both through maladaptive behaviours or cognitions, in line with the Ehlers and
Clark (2000) formulation. Therefore, it is important that patients continue to engage with the
later phases of ‘re-processing’ and ‘re-integration, beyond stabilisation.
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Given that there is no control, it is important to consider the participants views of
what contributed to their symptom improvement. As indicated by the results of the feedback
questionnaire, a majority of the participants agreed that they learned strategies to manage
their PTSD symptoms effectively. This supports but does not validate the notion that the
course is responsible for symptom reduction. Aside from this, the feedback suggests that the
course was well received by the participants, although the length of the course was
questioned by some. Given that the course was valued by the participants, the desire for the
course to be extended was expected. However, given the lack of evidence to suggest that it
would contribute to recovery, this does not appear necessary and may delay the therapeutic
improvements conferred by one-to-one TF-CBT (De Jongh et al., 2016).
Given the identified barriers and facilitators, the courses ability to meet the goals of
patients and practitioners appears feasible. Participants outlined that the course helped them
to meet their goals by enhancing their understanding of symptoms, providing techniques
supplemented with materials and via effective facilitation. It also enabled them to engage
with others with PTSD, which may have permitted vicarious learning and normalised
difficulties (Yalom, 1995). On the other hand, symptoms of mental health difficulties, stigma
and practical issues appeared to impede goal attainment. The four-session limit emerged as
the greatest barrier for participants, which may have prevented a sense of longevity or
individualisation required to attain goals (Morrison 2001).These barriers and facilitators
perceived by the participants corroborated with the perspectives of the practitioners who
attended the focus group. In addition, practitioners highlighted that the course aided their
patient’s risk management and reduced the number of sessions required for the patient to
meet their recovery goals. However, practitioners also suggested that their patients may not
have benefitted from the course given the complexity of their difficulties or due to life
stressors. Furthermore, it was apparent that the course may not have been effectively utilised
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by practitioners to meet patient goals, given a lack of understanding or awareness of it.
Finally, practitioners observed that their patients deteriorated after the course ended, although
the reason for this is unclear.
The current study is subject to various limitations. Most importantly, the study is
lacking internal validity given the naturalistic design and therefore, symptom improvement
may be the result of several uncontrolled variables. The sample is also heterogeneous as it
included individuals who met the criteria of either C-PTSD or PTSD and given a small
sample size, group comparisons could not be achieved to determine differential effect.
However, all participants were screened as requiring stabilisation input beforehand, which
served as the main focus of the study rather than problem descriptor.
Despite these limitations, the study is the first published effectiveness and feasibility
evaluation of a group stabilisation course delivered in an IAPT service. Given the naturalistic
design, the findings have high external validity and are applicable to NHS primary-care
settings. Future providers of similar interventions should carefully consider the identified
barriers and make adjustments accordingly to overcome them. Researchers should also
consider future controlled studies to build on the current effectiveness findings. The authors
conclude that group-delivered stabilisation is a feasible, highly valued and possibly effective
intervention that gives patients an opportunity to prepare for TF-CBT whilst on lengthy wait-
lists.
Acknowledgements: We express our thanks to the service users who took part in the study
and those practitioners who took part in the focus group.
Financial Support: This research received no specific grant from any funding agency,
commercial or not-for-profit sectors.
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Table 1
Sample characteristics of invited participants and those who attended all sessions
Characteristic
Invited to the course (N = 26)
Attended 4 sessions (N = 22)
Gender
Male
Female
10 (38.5.9%)
16 (61.1%)
7 (31.8%)
15 (68.2%)
Mean age in years (SD)
45.81 (14.63)
46.7 (14.61)
Ethnicity
White British
White Other
Black
Asian
Mixed
9 (34.6%)
3 (11.5%)
6 (31.1%)
5 (19.2%)
3 (11.5%)
9 (40.9%
2 (9.1%)
5 (22.7%)
4 (18.2%)
2 (9.1%)
Problem Descriptor
PTSD
C-PTSD
17 (65.4%)
9 (34.6%)
14 (63.6%)
8 (36.4%)
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Table 2
Mean and range scores for outcome measures at pre- and post-intervention with inferential
statistics
Pre-intervention
Post-intervention
Wilcoxon U
Measure
Mean (SD)
Range
Mean (SD)
Range
U
p value
IES-R
INT
AV
HYP
63.69 (10.65)
25.04 (3.99)
21.65 (6.29)
17.04 (4.54)
35-85
7-31
30-10
2-24
54.36 (14.42)
21.59 (6.91)
17.82 (5.93)
14.95 (5.13)
27-75
7-31
5-28
5-23
-3.40
-3.14
-2.11
-2.87
001*
.002*
.034*
.004*
GAD-7
16.23 (4.28)
5-21
13.41 (5.42)
5-21
-2.76
.006*
PHQ-9
17.31 (6.78)
3-27
14.59 (6.24)
3-25
-1.38
.168
WSAS
21.46 (7.89)
6-35
18.23 (8.00)
4-35
-1.27
.206
* p < .05. INT = Intrusion; AV = Avoidance; HYP = Hyper-arousal.
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0 5 10 15 20 25
Met needs
Adequate length
Clear Presentation
Confidence in therapists
Treated with dignity & respect
Adequate group size
Helpful to meet others
Helped understanding of trauma
Learned stategies
Feel more prepared for therapy
Recommend to others
Strongly
Agree
Agree
Neutral
Dis agree
Strongly
Dis agree
Figure 1. Bar charts to represent the frequencies of feedback questionnaire item responses.
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