Outcomes from a pilot study to evaluate Phase 1 of a two-phase approach to treat women with complex trauma histories

ABSTRACT

Objective

Despite few studies assessing the effectiveness of phase-based interventions for treating complex trauma symptoms, such approaches have been endorsed by experts as a first-line intervention. The aim of this study was to evaluate Phase 1 of the Women’s Trauma Recovery Program, a phase-based intervention for women who have experienced complex trauma.

Methods

Quantitative assessments of posttraumatic stress, depression, anxiety and stress (baseline and Week 10) are reported for 11 participants. Six women also participated in qualitative interviews regarding their experience of the program. Descriptive statistics and interpretive phenomenological analysis were used to analyse quantitative and qualitative data, respectively.

Results

Four of nine participants with probable PTSD at baseline were asymptomatic at Week 10. Three superordinate themes were generated from the interview data: (1) Empowerment: the experience in Phase 1, (2) Recovery: an ongoing process, and (3) “Hey, I’m human”: connection through shared experience.

Conclusion

Phase 1 of the program demonstrated promising findings in terms of symptom improvement. Furthermore, participants perceived it as an empowering experience. The group modality enabled women to create connections that validated and normalised their experiences. Future studies of phase-based interventions with larger, well-powered samples are needed.

Key Points

What is already known about this topic:

(1) Phase-based approaches are a recommended treatment option for individuals with complex trauma histories. Despite this, little research has examined such treatments for women who have experienced complex trauma.

(2) Phase-based approaches assume that individuals who have experienced complex trauma may benefit from a period of safety and stabilisation, to develop the required coping skills to engage in trauma memory processing.

(3) Capitalising on the Australian Medicare Rebate Scheme, combining a group phase and individual phase may reduce the cost burden for clients and enable clients to experience benefits unique to group and individual modalities.

What this topic adds:

(1) This paper presents Australian-first findings regarding the outcomes of the initial phase of a phase-based approach to treat women with complex trauma.

(2) Phase 1 of the Women’s Trauma Recovery Program, delivered in a group format, was associated with decreases in mental health symptoms for most participants and was perceived as empowering experience that facilitated interpersonal connections.

(3) Using a group intervention as phase 1 of phase-based approaches may be an acceptable, effective, and cost-effective option for women with complex trauma histories.

KEYWORDS:

• Complex trauma
• group therapy
• interpretive phenomenological analysis
• phase-based intervention
• psychoeducation
• women

The impact of prolonged and repeated interpersonal violence, including sexual abuse, neglect and abandonment, especially during childhood, has been well-researched (Dye, 2018). Such experiences, especially when perpetrated by a caregiver, have been termed “complex trauma” (Courtois, 2004) and studies have linked these experiences with the development of posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD; Hyland et al., 2017).

Phase-based approaches that combine an initial safety and stabilisation phase with Prolonged Exposure (PE) have demonstrated effectiveness in addressing interpersonal issues and symptoms of avoidance, arousal and re-experiencing in survivors of childhood abuse (Cloitre et al., 2010). Introduced by Herman (1992), phase-based approaches assume that individuals who have complex trauma histories and those with CPTSD benefit from a period of safety, stabilisation and skill-building before engaging in trauma memory processing, such as PE. This rationale suggests that individuals with CPTSD have fewer effective coping strategies and more complex symptoms and functional impairment than those with PTSD. Despite some promising evidence to support the application of such approaches (Cloitre et al., 2010), some researchers have been critical of this approach, suggesting that phase-based approaches may delay treatment (De Jongh et al., 2016). Indeed, recent evidence suggests that unimodal interventions for CPTSD are effective (Voorendonk et al., 2020).

In their critical review of single-phase and phase-based treatments for CPTSD, Dyer and Corrigan (2021) highlight that there is a significant point of overlap between unimodal and phase-oriented treatment, noting unimodal approaches do have aspects of phase-delivered treatment. For example, Trauma Focused Cognitive Behaviour Therapy will draw on strategies such as breathing retraining, behavioural activation and such for stablisation. The point of difference may then come from phase-based treatment tending to incorporate a range of treatment modalities into practice. Given this, the authors recommended that further research be conducted on the initial stabilisation treatment of phase-based interventions. Such research is needed to determine what combination of components is most effective for phase-based interventions (Dyer & Corrigan, 2021).

Trauma treatment is typically delivered on an individual basis; however, a growing body of research has indicated that standalone group interventions are also effective (Schwartze et al., 2019). For example, group interventions have reduced PTSD symptoms (Dorrepaal et al., 2010; Sayın et al., 2013; Schwartze et al., 2019), self-harm behaviours and substance use (Karatzias et al., 2014), and depression and anxiety (Sayın et al., 2013). In fact, Dorrepaal et al. (2010) and Karatzias et al. (2014) concluded that group psychoeducation shows promise in addressing and reducing symptoms associated with complex trauma. Reduced shame and stigma, increased hope and motivation through mutual aid and reduced social isolation have been observed in group interventions (Schmalisch et al., 2010), including in trauma populations. Through their qualitative findings, Karatzias et al. (2014) found that group treatment enabled peer support, which normalised participants’ internal experiences, an outcome that may be harder to achieve in one-on-one therapy.

A phase-based treatment in which the first phase is delivered in a group setting and with emphasis on psychoeducation over sharing experiences may facilitate a deeper understanding of symptoms and ease clients into the treatment process. Indeed, in qualitative interviews with 13 women who participated in stabilisation group therapy, Stige et al. (2013) found that important aspects of the group were sense of connection, normalisation of experiences and competence to manage symptoms. The importance of interpersonal connections in the treatment of complex trauma has also been underscored by psychologists (Beaton & Thielking, 2020). Finally, delivering an initial psychoeducation, safety and stabilisation phase in a group setting may be cost-effective and increase treatment accessibility (de Boer et al., 2021).

The purpose of the current study was to evaluate Phase 1 of the Women’s Trauma Recovery Program (WTRP), a phase-based treatment for women who have experienced complex trauma. The WTRP provides group psychoeducation, safety and stabilisation (Phase 1), followed by individual trauma memory processing (Phase 2). Aim 1 was to explore participants’ experience of Phase 1 of the WTRP, including acceptability. Aim 2 was to characterise the impact of the intervention on trauma and stress related symptoms.

Method

Participants

Participants were adult women with histories of complex trauma who completed one of two iterations of the WTRP between March 2018 and September 2018. Eleven of 14 women who completed Phase 1 consented for their assessment data to be used for research purposes and to be contacted for a follow-up interview; six women completed a follow-up interview.

Women’s trauma recovery program

The WTRP is phase-based intervention for women with a history of exposure to complex trauma, and experience associated psychological distress. It was not compulsory for women to meet diagnostic criteria of CPTSD and comprises two phases. This program was informed by the work of Courtois and Ford (2012) and Herman (1992). The program was structured to fit within and to take advantage of the Australian mental health reimbursement scheme, which rebates 10 group and 10 individual mental health sessions annually (Medicare Benefits Scheme, 2020).

Phase 1 of the WTRP is a 10-week group intervention that focuses on psychoeducation, stabilisation and safety. The purpose of Phase 1 is to prepare participants for trauma memory processing in Phase 2 through enhancing emotion regulation and coping skills. Psychoeducation includes: typical experiences of individuals who have experienced complex trauma, understanding and identifying trauma triggers, and connecting traumatic memories with bodily feelings and sensations. Participants are discouraged from sharing their trauma histories and to focus on their experience of the “here and now”. Phase 1 was co-delivered by a clinical psychologist with trauma treatment expertise DW and provisional psychologists who were completing masters-level training in clinical psychology.

Phase 2 of the WTRP involved individual trauma memory processing based on an Internal Family Systems framework, with the flexibility to incorporate other intervention strategies, such as EMDR or Art Therapy. Flexibility allowed consideration for client preference and clinical formulation. Phase 2 was delivered by DE, an Accredited Mental Health Social Worker with extensive training in both therapeutic techniques. The current study evaluated Phase 1 exclusively.

Procedure

Participants were self or professionally referred to the WTRP, which was facilitated in a university-based psychology clinic in Victoria. Individuals who identified as women and reported surviving exposure to complex trauma (e.g., multiple, interpersonal traumatic experiences such as prolonged domestic violence or childhood abuse as per the ICD-11 CPTSD criteria (World Health Organisation [WHO], 2022)) were eligible. Women who had experienced single-event trauma were excluded. Following a brief phone screen, prospective participants were invited to attend an assessment session to ascertain suitability of the treatment for their needs and goals.

That assessment session involved a 2-hour face-to-face session with the group facilitators, during which their trauma history, symptoms were screened and goals for the WTRP were queried. Participants were encouraged to establish or to maintain health and mental health supports (e.g., general practitioner, psychologist) for the duration of the program. Women for whom the WTRP was determined not to be a good fit (e.g., reporting non-interpersonal trauma, active drug use) were provided with appropriate referrals. To ensure treatment accessibility, no cut-off criteria on symptom measures were used in terms of participant eligibility.

Participating in the WTRP was not contingent on research participation. The WTRP was initially developed as a standalone treatment, without a research component, and all assessment and measures were completed as part of standard clinical practice and established in the intervention procedure. The research project was subsequently developed to evaluate the outcomes associated with the WTRP, and during the final session, group participants were informed about the intended study and provided the option to take part in the research. This included allowing the researchers to access their assessment materials and measures and participation in the qualitative interview. A written informed consent was obtained from all participants in the study. Procedures were approved by the Institutional Review Board at Swinburne University of Technology, SHR Project 2018/059.

Qualitative data collection

Semi-structured interviews were conducted face-to-face or by phone by KdeB a PhD candidate/provisional psychologist completing postgraduate training in clinical psychology. Interviews were able to be completed over the phone to facilitate ease of participation for individuals. Interviews lasted 30 to 90 minutes; participants were provided a $20 voucher for their time. Interviews were audio-recorded and transcribed verbatim by the interviewer. Participants were invited to review their transcript and to offer additional comments and corrections before analyses.

Quantitative data collection

Participants completed the following measures at their assessment interview (baseline) and at completion of Phase 1 of the WTRP (Week 10). Symptom measures were chosen to capture symptoms associated with complex traumatic experiences.

Adverse childhood experiences (ACE) checklist

The ACE checklist assesses adverse experiences prior to age 18 years with 10 yes/no questions (Felitti et al., 1998). Categories include: emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, parental separation or divorce, witnessing intimate partner violence, living with someone who used drugs, living with someone who was mentally ill or suicidal and living with someone who went to prison (Felitti et al., 1998). This measure was administered at baseline only.

Depression anxiety and stress scale-21 (DASS-21)

The DASS-21 is a 21-item self-report measure designed to assess depression, anxiety and stress over the past week (Lovibond & Lovibond, 1995). Scores range from 0 to 63; higher scores indicate greater distress. Established cut-off scores classify symptoms into normal, mild, moderate, severe and extremely severe levels. The DASS-21 has demonstrated good psychometric properties, including good internal consistency (Cronbach’s alpha =.81 to .88; Osman et al., 2012), good test-retest reliability (Gomez et al., 2014) and excellent validity (Antony et al., 1998). In the current sample, Cronbach’s alpha at baseline and Week 10 were .91 and .96, respectively.

Difficulties in emotion regulation scale-short form (DERS-SF)

The DERS-SF is an 18-item self-report tool (Kaufman et al., 2016), shortened from the original 36-item measure developed by Gratz and Roemer (2004). The DERS-SF consists of six subscales and produces a total score. Total scores range from 18 to 90; higher scores indicate greater difficulties with emotion regulation. The DERS-SF has good psychometric properties in adolescent and adult samples, including test-retest reliability and internal consistency (Cronbach’s alpha .89 to .91; Kaufman et al., 2016). In the current sample, Cronbach’s alpha at baseline and Week 10 were .85 and .89, respectively.

Posttraumatic stress check list – civilian version (PCL-C)

The PCL-C is a 17-item self-report measure that assesses the core criteria of PTSD per the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; Weathers et al., 1994). Scores range from 17 to 85; higher scores indicate more PTSD symptoms. Scores above 50 indicate probable PTSD. The PCL-C has good internal consistency in diverse samples, such as cancer patients (Cronbach’s alpha =.93; Mager & Andrykowski, 2002) and motor vehicle collision survivors (Cronbach’s alpha =.93; Blanchard et al., 1996), and good test-retest reliability (Wilkins et al., 2011). In the current sample, Cronbach’s alpha at baseline and Week 10 were .90 and .93, respectively.

Data analysis

Quantitative outcome data were summarised using descriptive statistics. Due to small sample size, inferential analyses were not performed. Interpretative phenomenological analysis (IPA) was used to analyse interview data. IPA consists of seven steps (see Figure 1; McCormack & Joseph, 2018).

Figure 1. Steps involved in interpretative phenomenological analysis (McCormack & Joseph, 2018).

IPA is increasingly common in psychological research (Lawrence & Lee, 2014) and was chosen as it focuses on the individual experience, including how individuals make sense of their unique context, and is suitable for generating insight into complex situations (McCormack & Joseph, 2018). Rather than establishing a priori hypotheses, IPA enables researchers to explore data through an iterative process to clarify the meaning an individual makes of their lived experience. Qualitative data were managed via Microsoft Excel.

To ensure data reliability, CA, a post-doctoral researcher with experience in qualitative research, clinical psychology and trauma treatment, independently coded half of the interviews alongside the first author. Coders met regularly to discuss similarities and discrepancies in emergent themes, consistency in interpretation and biases observed during engagement with and interpretation of data. No major discrepancies were noted. The first author maintained a reflexivity journal during the analysis process to reflect on how their personal experience, data expectations and biases may have influenced their interpretation process (Darawsheh & Stanley, 2014).

Results

The 11 participants had an average age of 36.7 years (SD = 8.14) and endorsed a mean of 5.6 (SD = 1.86, range 3 to 9) ACEs. The most common ACE was emotional neglect (90.9%). Furthermore, 72.7% of the sample reported experiences of emotional abuse, with the same percentage experiencing physical or sexual abuse, or living with someone at home who had mental health issues.

Qualitative results

Three superordinate themes were generated: (1) Empowerment: the experience in the Women’s Trauma Recovery Program, (2) Recovery: an ongoing process, and (3) “Hey, I’m human”: connection through shared experience. Themes were broken into sub-themes to characterise nuances of the women’s experiences.

Empowerment: the experience in the women’s trauma recovery program

“Knowledge is power”

During Phase 1, participants learned language to name their experiences (e.g., hyperarousal) in a space that enabled safe exploration of their symptoms and internal experiences. Chantal reflected that the understanding she developed enabled her to respond differently to some of the symptoms she experienced, “It now gives me the unique opportunity to look at a situation and notice…I can now actively choose whether I wish to stay in that state [hypoarousal or hyperarousal], or whether I need to move into another one”.

Several participants reflected that learning about their internal experience and its impacts on their day-to-day life demystified their internal worlds and facilitated a sense of control over their experiences. Evelyn reflected, “Now I am able to…name things a little bit more…I understand what’s going on in my body or in my thinking and [I’m] less afraid or trying to push it away…knowledge is power”.

The theme of empowerment arose again when the participants spoke about the choices offered in the WTRP, such as in what activities they engaged and how active they were in the group. This created the sense that participants were active agents in their recovery. Andrea, Laura and Evelyn shared this experience in their interviews. For example, Andrea shared, “When you’ve had people come from … relationship abuse, where there’s not a lot of choice, introducing choice is really empowering and strengthens people’s sense of autonomy…at every point there were those options”.

Hope for recovery

Hope for recovery appeared to have been supported by the emotional validation that participants received from one another and the facilitators, alongside psychoeducation, which increased their understanding of their experiences. Evelyn, Chantal and Andrea shared that after participating in the WTRP, they felt hope that life did not have to continue as it had before; there were opportunities to heal. Chantal stated, “This is…more hope than I’ve had in the past…it feels like there’s a bit of a way out…or being able to work with those aspects”.

Self-compassion

Participants linked their increasing understanding of their inner experiences to expressions of kindness towards themselves and a shift away from self-blame. Chantel concluded, “I have definitely uncovered more things about myself that I didn’t have awareness of before…I am not expecting to be perfect, I just want to be okay”. The theme of self-compassion was particularly salient for Evelyn, who stated, “I also found it really helpful looking at self-compassion … moving away from that model of ‘I am wrong’…recognising those unhealthy responses had a purpose and helped…it helped me to feel less judgemental about that”.

Evelyn spoke further about how her experience in the group empowered her to shift her relationship with her inner critic. Shifting away from self-blame and thoughts that something was wrong with her were therapeutic for her. She found it empowering to recognise that the inner critic is an aspect of herself, not her whole self.

Recovery: an ongoing process

Stages of recovery

Prior to the WTRP, several participants had sought other forms of psychological support. Despite this, participants identified unique aspects of Phase 1. For example, Zoe and Laura mentioned that body tapping, a grounding technique, was a coping strategy they had not been introduced to previously. Evelyn reflected on skill-building, “I feel like over time I’ve been getting just more skills and resilience and I can kind of ride things out a little bit more”.

Focus on the “here and now” was seen as a positive and unique experience for both Laura and Evelyn. Laura shared, “The approach where you don’t actually have to talk about any traumas was … refreshing because in the past they’ve always been like ‘You should tell people about this awful thing that happened’, and [it’s] kind of re-traumatising”.

Participants spoke of treatment and recovery as an ongoing process involving “stages” of healing. Both Chantal and Evelyn spoke about the WTRP coming at a good time in their lives and being a good fit for their recovery needs. Chantal said, “I am still struggling with…social connections…I’ve had triggers recently where I don’t feel safe again … I think it just kind of came at the right time”. Conversely, Zoe found that Phase 1 added little to her healing experience, given her current stability. She stated, “I’m just at a pretty stable point at the moment so I didn’t get a lot out of that”.

Although several participants concluded that Phase 1 contributed to their recovery process, some participants indicated that it was not sufficient to meet their needs and that they believed further therapeutic work was necessary. Rowena, Laura and Chantal felt they needed longer in the group and/or more information and exploration of certain topics. For example, Rowena stated, “Because [my trauma] stems right back down to childhood…it went a bit too fast”.

Participants were encouraged to maintain external support and connections (e.g., psychologist). Some participants, including Chantal and Evelyn, commented that accessing additional supports outside the WTRP was beneficial to helping them to further unpack and process content delivered in the group. Chantal stated, “I really enjoyed the time when I had the outreach worker…we’d talk about it and then I unpacked it further, so that really pushed it for me”.

Accessible and manageable

When participants reflected on their previous treatment experiences, several commented on barriers they had faced, one of which was treatment access. Accessibility was understood as the client’s capacity to engage with the treatment on a practical level (e.g., cost, delivery, digestibility of content). Rowena disclosed experiencing financial hardship in accessing a trauma specialist. For her, the WTRP was both manageable and cost-effective. Andrea and Evelyn spoke about Phase 1 being accessible in terms of information delivery. Specifically, Evelyn reflected, “[Information] was presented in a way that was really acceptable, gentle and compassionate”.

“Hey, I’m human”: connection through shared experience

Phase 1 of the WTRP provided women space to connect and share experiences, which normalised and validated one another’s emotions and led to dialogue about shared experiences. Rowena reflected, “You don’t feel as much of as freak…it’s not just you…you understand yourself a little bit more and that hey I am human…that was another big thing for me too, never feeling human [prior to the WTRP]…always feeling wrong”. Connection through shared experience also reduced the sense of isolation some of participants felt. Evelyn shared, “There’s a great value to…recognising each other…being vulnerable but also everyone…being united in this healing journey…makes you feel less alone”.

Some participants described other gains from interacting with fellow group members. For example, Chantal stated that she “[didn’t] just gain stuff out of the course content” but that “the other women in the group helped [her] with certain things, too”. This was echoed by Laura who stated, “It was just nice having a group of people as well … asking questions that I might not have necessarily asked…have the insights that I might not have had. It’s helpful”. Similarly, Zoe felt she was able to offer something to fellow group members, “I felt like I gave tips where I had tips, so hopefully that was useful”.

Cultivation of a safe and supportive environment also contributed meaningfully to some participants’ positive experience of the WTRP. Chantal shared, “I think there’s also something really healing about being in a group setting, that it felt really safe…being in a women’s-focused group…it felt safer”. The sense of safety and support that was developed in the group was echoed by Andrea, “There is no responsibility to be ‘on’ in the way direct therapy offers, so…you can be a bit spacey … everyone is acknowledging you…in a way, the nurturing you didn’t get in a relational sense, you do get in the group”. Going beyond creating a safe and welcoming space, Rowena felt a sense of commitment to the group, which encouraged her to attend even when she was struggling. She shared, “I was having really bad day…I almost didn’t come…but I did come…because the [group] dynamics was good, so I was able to push through whatever was going on”.

Quantitative results

Pre and post measure scores are presented in Table 1. Using a cut-off score of 50 for the PCL-C (Weathers et al., 1994), nine of the 11 participants screened for probable PTSD at baseline. Four of the nine participants (67%) were asymptomatic at Week 10. Using the predefined severity cut-off scores on the DASS-21 (Lovibond & Lovibond, 1996), five participants (55%) demonstrated improvement in depression classification (i.e., moderate to normal [n = 2], moderate to mild [n = 2], mild to normal [n = 1]). Three participants’ (33%) anxiety decreased (i.e., moderate to normal [n = 2], severe to moderate [n = 1]) and two (22%) participants’ stress level decreased (i.e., mild to normal). Alongside these improvements, one participant reported increased depression (i.e., normal to mild) and anxiety (i.e., moderate to severe) on the DASS-21 and stress on the DASS-21 increased for three participants (i.e., mild to extremely severe [n = 2], normal to severe [n = 1]). Of note, among the three participants for whom a single DASS-21 subscale classification worsened in severity, their overall DASS-21 score declined. No cut-off scores or metrics of clinically significant change have been published for the DERS-SF scale; however, an average decrease of 12.8 was observed across six participants. Regarding the remaining 5 participants, data at week 10 was not available for three of the women, no change was reported by one participant and finally one participant reported an increase in the DERS-SF from baseline to week 10.

Table 1. Participant total scores on measures administered during Phase 1 of the women’s trauma recovery program.

Participant	DASS-21			DERS-SF			PCL-C
	Baseline	Week 10	Change	Baseline	Week 10	Change	Baseline	Week 10	Change
Rowena^†	39	23	−16	52	40	−12	63	48	−15^‡
Andrea^†	31	21	−10	51	39	−12	50	36	−14^‡
Zoe^†	15	9	−6	37	35	−2	37	33	−4
Laura^†	52	19	−33	-	57	-	64	61	−3
Evelyn^†	39	10	−29	54	44	−10	52	40	−12^‡
Chantal^†	37	10	−27	52	56	4	62	58	−4
Ida	43	8	−35	67	39	−28	60	33	−27^‡
Nikola	41	38	−3	67	54	−13	60	63	3
Jayne	16	4	−12	41	41	0	25	19	−6
Maisha	25	-	-	46	-	-	57	-	-
Alayna	48	-	-	66	-	-	73	-	-

DASS-21 = Depression, Anxiety and Stress Scale, DERS-SF = Difficulties in Emotion Regulation Scale – Short Form, PCL-C = Posttraumatic Stress Check List – Civilian Version. Pseudonyms have been used to protect participant confidentiality.

^†Participants who provided qualitative data.

^‡Participants who no longer met a probable PTSD diagnosis at baseline. Cut-off scores have not been published for the DASS-21 total, thus have not been indicated in the above table.

Discussion

The objective of this study was to assess Phase 1 of the WTRP, a phase-based treatment for women who have experienced complex trauma. The aims of this paper were to investigate whether symptoms were reduced, as has been observed in previous research (Dorrepaal et al., 2012), and to explore participants’ experiences of the initial psychoeducation, safety and stabilisation group intervention.

Despite not being designed to be a standalone intervention, several participants reported symptom declines over the 10 weeks. It was particularly promising that of the nine women who screened positive for probably PTSD at baseline, four no longer met diagnostic criteria. Furthermore, five, three and two women demonstrated declines in depression, anxiety and stress, respectively. Given the intention of Phase 1 of the WTRP was to support stabilisation, it is encouraging to note the decrease in self-reported emotion regulation difficulties. Six participants demonstrated an improvement in their ability to self-regulate, suggesting that Phase 1 may be effective at supporting individuals develop skills that may be valuable in subsequent trauma memory processing (Phase 2). Interventions targeting emotion regulation difficulties and teaching emotion regulation skills have been found to be a mediating factor in treatment for PTSD symptoms (Sharma-Patel & Brown, 2016). The small sample precluded inferential analyses. Future evaluations of the WTRP should recruit larger samples to ensure sufficient power to test the impact of Phase 1 on mental health symptoms.

Using IPA, the following superordinate themes were identified in qualitative interviews with six participants: (1) Empowerment: the experience in Phase 1, (2) Recovery: an ongoing process, and (3) “Hey, I’m human”: connection through shared experience. Phase 1 of the WTRP was perceived as an empowering experience and the group modality enabled participants to create connections with one another that validated and normalised their experiences. This is consistent with previous research findings (Karatzias et al., 2014; Stige et al., 2013), including the work of Sayın et al. (2013) who found universality, or shared experience, to be among the most helpful group therapeutic processes in an intervention for women survivors of sexual abuse. Perceived empowerment, choice and safety described by participants speaks to the importance of incorporating the trauma-informed care principles into group-based treatments for survivors of complex trauma. In addition to skills developed within the group that may have led to improvements in emotion regulation and mental health symptoms, other group factors may have contributed to symptom reduction. Research has found that perceived social support may be a meaningful therapeutic target for individuals with complex trauma (Simon et al., 2019). Indeed, research has consistently found that higher levels of social support is predictive of lower PTSD symptoms (Zalta et al., 2021). Further, increased self-compassion described by some participants may also have contributed to observed symptom reductions. In fact, previous research has found that self-compassion may be a worthwhile target when treating CPTSD, in that higher self-compassion was associated with reduced DSO and PTSD symptoms (Karatzias et al., 2018; Winders et al., 2020). Further investigation is warranted regarding the utility of targeting both of these areas.

Despite the aforementioned advantages, group work limits the extent to which interventions can be tailored to individual needs. Some participants desired the content to be delivered slower or in more detail. Several participants also expressed interest in extending the group phase or indicated the felt need for further treatment. This indicates that while safety and stabilisation is valuable, some participants need subsequent treatment to address trauma symptoms directly. This aligns with Dorrepaal et al. (2012) who highlighted that whilst a stabilisation phase may be beneficial, targeted treatment is often required to address trauma symptoms. This feedback underscores the potential value of a subsequent phase to cement skills and to delve deeper into trauma-focused work.

Several limitations are worth noting. Firstly, although all participants completed outcome measures in Week 10, time to interview varied across participants. For example, some women had already begun to Phase 2 prior to being interviewed regarding Phase 1. Given that Phase 2 involved one-on-one psychotherapy, it is unlikely that those experiences would have been conflated with those of the group treatment, which was the focus of interviews. While a strength of the WTRP was that participants were encouraged to continue ongoing engagement with other health and mental health professionals, it is possible that those supports contributed to symptom improvements and is an important limitation of the study. It was not the intention of the program to replace already established supports, however this should be considered in future studies. No control group was employed in this study and the sample size was underpowered for inferential analyses. Further, some of the sample presented with more recent trauma, for example intimate partner violence, thus symptom reduction may have been contributed to by natural remission. Additionally, although data on the ethnicity of participants was not collected, the WTRP was delivered in a western setting thus it is not clear how the intervention will translate into different cultural settings and with populations reporting different traumatic experiences such as refugee or war related trauma.

Measures used in this study were influenced by those in-use by the clinic where recruitment took place and did not include a measure specific to CPTSD. Moreover, ethics approval for this study coincided with the release of the International Trauma Questionnaire (Cloitre et al., 2018), a validated measure of CPTSD that was not yet in use by the clinic where recruitment took place. Thus, the ACE was used to assess for complex trauma experiences. Administration of a validated measure of CPTSD will be critical for future studies that examine treatments for CPTSD. Despite 91% of the sample being above cut off for probable PTSD, the baseline scores on the DERS are not especially elevated. For example, the current population reported a mean baseline DERS score of 53.3 compared to 98.4 (Cloitre et al., 2018) and 110.11 (Cloitre et al., 2021) in other populations reporting histories of complex trauma. Thus, the current sample may be more representative of PTSD rather than individuals presenting with complex symptomology or CPTSD. This further limits the conclusions that can be made in terms of Phase 1 of the WTRP addressing symptoms associated with CPTSD.

Previous research has noted that qualitative interviews that are conducted over the phone may typically go for a shorter duration (Irvine, 2011), and thus differences between face-to-face and telephone interviews are important to acknowledge. Indeed, the mean duration of telephone interviews was six minutes shorter than the face-to-face interviews, yet this might not necessarily mean a difference in data quality. Previous research that has also combined telephone and face-top-face interviews did not find a significant difference between modalities (Sturges & Hanrahan, 2004) however more research is required in this area.

Despite these limitations, this study demonstrated that a stabilisation-focused group intervention as part of a phase-based intervention was perceived to be an empowering and supportive experience that contributed to the recovery process for women who had survived complex trauma. Preliminary quantitative data indicated that the WTRP was associated with symptom improvement in several domains, including posttraumatic stress and depression. The qualitative data provided important clues as to what mechanisms may have contributed to observed symptom changes or worthwhile therapeutic targets (e.g., emotion regulation, self-compassion). Future studies should recruit larger samples and test this intervention against an active control condition to verify the effectiveness of the WTRP.

Acknowledgements

We wish to express deep gratitude to the women who participated in the research project and shared their lived experience. The researchers also acknowledge Access Health and Community who were partners in developing the Women’s Trauma Recovery Program. KdeB would like to acknowledge the Australian Government Research Training Program Stipend.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Due to the nature of this research, participants of this study did not agree for their data to be shared publicly, thus supporting data is not available.

Additional information

Funding

The work was supported by the Australian Government [Research Training Program Stipend].