The experience of trauma recovery: a qualitative study of participants in the Women Recovering from Abuse Program (WRAP)

Survivor, family and professional experiences of psychosocial interventions for sexual abuse and violence: a qualitative evidence synthesis

BACKGROUND

It is well-established that experiencing sexual abuse and violence can have a range of detrimental impacts; a wide variety of interventions exist to support survivors in the aftermath. Understanding the experiences and perspectives of survivors receiving such interventions, along with those of their family members, and the professionals who deliver them is important for informing decision making as to what to offer survivors, for developing new interventions, and enhancing their acceptability.

OBJECTIVES

This review sought to: 1. identify, appraise and synthesise qualitative studies exploring the experiences of child and adult survivors of sexual abuse and violence, and their caregivers, regarding psychosocial interventions aimed at supporting survivors and preventing negative health outcomes in terms of benefits, risks/harms and barriers; 2. identify, appraise and synthesise qualitative studies exploring the experiences of professionals who deliver psychosocial interventions for sexual abuse and violence in terms of perceived benefits, risks/harms and barriers for survivors and their families/caregivers; 3. develop a conceptual understanding of how different factors influence uptake, dropout or completion, and outcomes from psychosocial interventions for sexual abuse and violence; 4. develop a conceptual understanding of how features and types of interventions responded to the needs of different user/survivor groups (e.g. age groups; types of abuse exposure; migrant populations) and contexts (healthcare/therapeutic settings; low- and middle-income countries (LMICs)); 5. explore how the findings of this review can enhance our understanding of the findings from the linked and related reviews assessing the effectiveness of interventions aimed at supporting survivors and preventing negative health outcomes.

SEARCH METHODS

In August 2021 we searched MEDLINE, Embase, PsycINFO and nine other databases. We also searched for unpublished reports and qualitative reports of quantitative studies in a linked systematic review, together with reference checking, citation searches and contacting authors and other researchers to identify relevant studies.

SELECTION CRITERIA

We included qualitative and mixed-methods studies (with an identifiable qualitative component) that were linked to a psychosocial intervention aimed at supporting survivors of sexual abuse and violence. Eligible studies focused on at least one of three participant groups: survivors of any age, gender, sexuality, ethnicity or [dis]ability who had received a psychosocial intervention; their carers, family members or partners; and professionals delivering such interventions. We placed no restrictions in respect of settings, locations, intervention delivery formats or durations.

DATA COLLECTION AND ANALYSIS

Six review authors independently assessed the titles, abstracts and full texts identified. We extracted data using a form designed for this synthesis, then used this information and an appraisal of data richness and quality in order to stratify the studies using a maximum variation approach. We assessed the methodological limitations using the Critical Skills Appraisal Programme (CASP) tool. We coded directly onto the sampled papers using NVivo and synthesised data using a thematic synthesis methodology and used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We used a narrative synthesis and matrix model to integrate our qualitative evidence synthesis (QES) findings with those of intervention review findings.

MAIN RESULTS

We identified 97 eligible studies and sampled 37 of them for our analysis. Most sampled studies were from high-income countries, with four from middle-income and two from low-income countries. In 27 sampled studies, the participants were survivors, in three they were intervention facilitators. Two included all three of our stakeholder groups, and five included two of our groups. The studies explored a wide range of psychosocial interventions, with only one type of intervention explored in more than one study. The review indicates that features associated with the context in which interventions were delivered had an impact on how individuals accessed and experienced interventions. This included organisational features, such as staff turnover, that could influence survivors' engagement with interventions; the setting or location in which interventions were delivered; and the characteristics associated with who delivered the interventions. Studies that assess the effectiveness of interventions typically assess their impact on mental health; however, as well as finding benefits to mental health, our QES found that study participants felt interventions also had positive impacts on their physical health, mood, understanding of trauma, interpersonal relationships and enabled them to re-engage with a wide range of areas in their lives. Participants explained that features of interventions and their contexts that best enabled them to benefit from interventions were also often things that could be a barrier to benefiting from interventions. For example, the relationship with the therapist, when open and warm was a benefit, but if such a relationship could not be achieved, it was a barrier. Survivors' levels of readiness and preparedness to both start and end interventions could have positive (if they were ready) or negative (if they were not) impacts. Study participants identified the potential risks and harms associated with completing interventions but felt that it was important to face and process trauma. Some elements of interventions were specific to the intervention type (e.g. faith-based interventions), or related to an experience of an intervention that held particular relevance to subgroups of survivors (e.g. minority groups); these issues could impact how individuals experienced delivering or receiving interventions.

AUTHORS' CONCLUSIONS

We had high or moderate confidence in all but one of our review findings. Further research in low- and middle-income settings, with male survivors of sexual abuse and violence and those from minority groups could strengthen the evidence for low and moderate confidence findings. We found that few interventions had published quantitative and qualitative evaluations. Since this QES has highlighted important aspects that could enable interventions to be more suitable for survivors, using a range of methodologies would provide valuable information that could enhance intervention uptake, completion and effectiveness. This study has shown that although survivors often found interventions difficult, they also appreciated that they needed to work through trauma, which they said resulted in a wide range of benefits. Therefore, listening to survivors and providing appropriate interventions, at the right time for them, can make a significant difference to their health and well-being.

Interventions for adults with a history of complex traumatic events: the INCiTE mixed-methods systematic review

BACKGROUND

People with a history of complex traumatic events typically experience trauma and stressor disorders and additional mental comorbidities. It is not known if existing evidence-based treatments are effective and acceptable for this group of people.

OBJECTIVE

To identify candidate psychological and non-pharmacological treatments for future research.

DESIGN

Mixed-methods systematic review.

PARTICIPANTS

Adults aged ≥ 18 years with a history of complex traumatic events.

INTERVENTIONS

Psychological interventions versus control or active control; pharmacological interventions versus placebo.

MAIN OUTCOME MEASURES

Post-traumatic stress disorder symptoms, common mental health problems and attrition.

DATA SOURCES

Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 onwards); Cochrane Central Register of Controlled Trials (CENTRAL) (from inception); EMBASE (1974 to 2017 week 16); International Pharmaceutical Abstracts (1970 onwards); MEDLINE and MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (1946 to present); Published International Literature on Traumatic Stress (PILOTS) (1987 onwards); PsycINFO (1806 to April week 2 2017); and Science Citation Index (1900 onwards). Searches were conducted between April and August 2017.

REVIEW METHODS

Eligible studies were singly screened and disagreements were resolved at consensus meetings. The risk of bias was assessed using the Cochrane risk-of-bias tool and a bespoke version of a quality appraisal checklist used by the National Institute for Health and Care Excellence. A meta-analysis was conducted across all populations for each intervention category and for population subgroups. Moderators of effectiveness were assessed using metaregression and a component network meta-analysis. A qualitative synthesis was undertaken to summarise the acceptability of interventions with the relevance of findings assessed by the GRADE-CERQual checklist.

RESULTS

One hundred and four randomised controlled trials and nine non-randomised controlled trials were included. For the qualitative acceptability review, 4324 records were identified and nine studies were included. The population subgroups were veterans, childhood sexual abuse victims, war affected, refugees and domestic violence victims. Psychological interventions were superior to the control post treatment for reducing post-traumatic stress disorder symptoms (standardised mean difference -0.90, 95% confidence interval -1.14 to -0.66; number of trials = 39) and also for associated symptoms of depression, but not anxiety. Trauma-focused therapies were the most effective interventions across all populations for post-traumatic stress disorder and depression. Multicomponent and trauma-focused interventions were effective for negative self-concept. Phase-based approaches were also superior to the control for post-traumatic stress disorder and depression and showed the most benefit for managing emotional dysregulation and interpersonal problems. Only antipsychotic medication was effective for reducing post-traumatic stress disorder symptoms; medications were not effective for mental comorbidities. Eight qualitative studies were included. Interventions were more acceptable if service users could identify benefits and if they were delivered in ways that accommodated their personal and social needs.

LIMITATIONS

Assessments about long-term effectiveness of interventions were not possible. Studies that included outcomes related to comorbid psychiatric states, such as borderline personality disorder, and populations from prisons and humanitarian crises were under-represented.

CONCLUSIONS

Evidence-based psychological interventions are effective and acceptable post treatment for reducing post-traumatic stress disorder symptoms and depression and anxiety in people with complex trauma. These interventions were less effective in veterans and had less of an impact on symptoms associated with complex post-traumatic stress disorder.

FUTURE WORK

Definitive trials of phase-based versus non-phase-based interventions with long-term follow-up for post-traumatic stress disorder and associated mental comorbidities.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017055523.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 43. See the NIHR Journals Library website for further project information.

Sensory-based interventions with adult and adolescent trauma survivors

Purpose

An emerging evidence base, and increased awareness of the effects of trauma on the body, advocates a sensory-based approach to treatment with posttraumatic stress and complex trauma survivors. This paper aims to identify, analyse and summarise the empirical evidence for the sensory-based interventions, which occupational therapists are using in the treatment of adult and adolescent trauma survivors.

Design/methodology/approach

An integrative review of the literature was undertaken. Both empirical and conceptual papers were included. An inductive approach and constant comparative method were used to understand and synthesise the research.

Findings

The literature search yielded 18 papers describing the types of sensory-based interventions used, sensory processing (SP) patterns and the context and evidence for sensory-based occupational therapy practice with trauma survivors. Nine of the studies were empirical and nine were conceptual and review papers. Themes identified included: atypical SP patterns; type of sensory-based intervention used with trauma survivors; and transdisciplinary treatment programmes can reduce the symptoms of trauma.

Practical implications

Sensory-based interventions with adult and adolescent trauma survivors are emerging as promising areas of practice and research in the literature. Although empirical data is limited, the sensory needs of the body in processing trauma experiences is becoming more recognised and are supported by the atypical SP patterns identified in survivors. A sensory-based, transdisciplinary approach to treatment has the potential to be effective in treating the trauma survivor.

Originality/value

With a skill base in sensory integration and occupational analysis, occupational therapists have much to offer the field of trauma studies. This review begins to address the gap in the literature, recommending more rigorous controlled outcome research with larger sample sizes, person-centred studies focussing on the trauma survivor’s perspective and continuing professional development and mentorship for occupational therapists working with this population.

Piloting a psycho-social intervention for incarcerated women with trauma histories: lessons learned and future recommendations

Trauma and related mental health disorders are common among incarcerated women, but empirically sound mental health interventions are lacking in prisons. Implementing such interventions is fraught with legal and logistical barriers. These barriers can be particularly detrimental for trauma-specific interventions given the unique needs of trauma survivors, yet there is little documentation of these issues or how to address them. This study describes a pilot study of an 8-week, strengths-based, trauma-focused intervention for 26 incarcerated women. Women reported considerable mental health problems and trauma. The study highlights the importance of adapting stringent research methodologies for prison-based trauma interventions. For instance, women with trauma were reluctant to participate in an intervention advertised as trauma-based. Moreover, a randomized wait list control design was unfeasible because women wanted the support of their friends when discussing trauma and could not control their schedules 9 weeks in advance. Ultimately, this work may inform future efforts to implement effective trauma-based interventions behind prison walls.

Through the eyes of the wounded: a narrative analysis of children's sexual abuse experiences and recovery process

Numerous children receive counseling for sexual abuse, yet their personal perspectives related to the abuse, the impact of making the disclosure, and the recovery process are noticeably absent from the scholarly literature. This study addressed this gap by analyzing trauma narratives written by children as part of a counseling intervention. Qualitative analysis revealed three themes: memories of the abuse, the disclosure and subsequent events, and the healing journey. Children's descriptions of their thoughts, feelings, and beliefs about their experiences are delineated and recommendations are provided for counseling professionals to increase the efficacy of care provided.

Stories from the road of recovery - How adult, female survivors of childhood trauma experience ways to positive change

The aim of this study was to explore how female survivors of childhood trauma who have sought treatment experience ways to positive change. Little knowledge exists regarding the first-person perspective of the recovery process following childhood trauma, and getting access to this perspective might contribute to better understanding of these processes, hence offering opportunities for health promotion. All clients (31, including 3 who dropped out) from six stabilization groups for women exposed to human-inflicted traumas were invited to participate in the study. Experiences of the recovery process were not restricted to the period of receiving treatment, and all clients who volunteered were included in the study. Qualitative, in-depth interviews with 13 consenting clients were carried out shortly after completion of the group treatment. All interviews were transcribed verbatim, and a hermeneutical-phenomenological approach to analysis was applied. The analysis resulted in five interrelated, but distinct main themes: finding new ways to understand one's emotions and actions, moving from numbness toward vital contact, becoming an advocate of one's own needs, experiencing increased sense of agency, and staying with difficult feelings and choices. The themes support, yet supplement trauma theory, by underlining the relationship between emotional contact and meaning-making, while downplaying the necessity of symptom elimination in the experience of recovery. The findings also underline that the active role trauma survivors play in their processes of recovery.

A meaningful struggle: trauma clients' experiences with an inclusive stabilization group approach

The present study explores how trauma clients experience participation in an inclusive stabilization group approach. Upon completion of treatment, all 31 clients from six stabilization groups for women were invited to participate in a qualitative post-therapy interview study. Thirteen clients consented to participate. All interviews were carried out by a team of three health-care workers shortly after completion of treatment. Five main themes were identified: Dreading and Hoping-Preparing for Participation; Tuning in and Staying Put; Meeting Other Trauma Survivors; Acquiring a Stabilizing Ballast; and Being Receptive to Change. Participating in the stabilization group was experienced as demanding, while also providing new and helpful experiences. Participants emphasized the importance of being receptive to help in order to benefit from treatment.

Prediction of sexual trauma via disruption of sex-aggression associations

A variant of the Implicit Association Test focusing on the association of sexual and aggressive themes was administered to 90 college students (61 women) and correlated with a series of variables based on participant history of sexually traumatic events. A history of sexual abuse was correlated with increased difficulties in processing sexual and aggressive concepts simultaneously. Furthermore, this relationship remained significant after controlling for general level of emotional distress, and even after controlling for self-reported aggressiveness and positive feelings towards sex. The findings provide grounds for further exploration of deficits in associations between sexual and aggressive concepts as a possible indicator of the cognitive effects of sexual abuse.