Making Sense of Change after Intensive Trauma Treatment; a Mixed- Method Study into Adolescents Experience of Efficacy

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Making Sense of Change after Intensive Trauma Treatment; a Mixed- Method Study into Adolescents Experience of Efficacy

https://doi.org/10.21203/rs.3.rs-3981761/v1

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While evidence-based interventions are effective for children with post-traumatic stress disorder (PTSD), some adolescents may not respond sufficient. Intensive trauma treatment (ITT) has shown promise for adults, but research on its efficacy for adolescents is limited. This study adopts a mixed-method approach, combining clinical data and narratives, to explore the efficacy and subjective experience of change in 22 adolescents participating in ITT. Quantitative analysis revealed a significant reduction in PTSD symptoms post-ITT, aligning with prior research. Qualitative analysis highlighted themes such as negative thoughts impacting treatment success, the importance of social support, and identity-related struggles. The study contributes to understanding ITT efficacy and emphasizes the need for developmental sensitivity, systemic interventions, and continued research to enhance PTSD treatment for adolescents.

PTSD

trauma treatment

adolescence

social support

identity

Adverse childhood experiences (ACEs) constitute a considerable public health issue, exerting enduring effects on the psychological, emotional, and social well-being of those affected (Cohen & Scheeringa, 2022; McLaughlin et al., 2020). Epidemiological studies reveal the pervasive nature of exposure to various traumatic events among youth globally, including physical or sexual violence, mass conflict, serious accidents, natural disasters, domestic abuse, and neglect (Redican et al., 2022; Morina et al., 2016; Landolt et al., 2013). General population estimates indicate that one to two-thirds of children undergo potentially traumatizing events before the age of 16 (Copeland, Keeler, Angold, Costello, 2007; Lewis et al., 2019). Approximately 16% of these exposed children and adolescents develop post-traumatic stress disorder (PTSD; Alisic et al., 2014), with heightened risks of comorbid depressive symptomatology (Dixon et al., 2005), addiction (Zarse et al., 2019), and/or developmental problems (Artz et al., 2014).

In recent years, there has been an increased recognition of the need for effective trauma-focused interventions tailored specifically to children and young adolescents. Previous research provides substantial evidence for the efficacy of various evidence-based interventions, including Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; Lee & Lang., 2023; Hoppen et al., 2023) and Eye Movement Desensitization and Reprocessing (EMDR; Beer., 2018; Moreno-Alcázar et al., 2017). However, for a subset of youth, particularly those with more complex, interpersonal trauma and/or comorbid psychopathology, evidence-based guideline treatments may not always be as effective and accessible. Not all children and adolescents exhibit sufficient improvement, and dropout rates from trauma-focused treatment remain concerning (van der Hoeven et al., 2023; Eslinger et al., 2023; Ormhaug & Jensen, 2018).

A potential solution to these challenges involves enhancing current guideline treatments by integrating treatments and condensing sessions into a shorter timeframe, creating an intensive trauma treatment program (Woudenberg, 2018). Intensive trauma treatment (ITT) targeting adults has shown promising results in reducing PTSD symptoms and overcoming avoidance behaviors (Bongaerts et al., 2022; Voorendonk et al., 2020; Hendriks et al., 2018). Despite being considered a safe, accessible treatment for adults with PTSD (de Jongh et al., 2020), a significant gap remains in our understanding of the effectiveness of ITT for children and adolescents. Nevertheless, research results indicate that ITT for adolescents can potentially be safe and effective, but more research is necessary (Van Pelt et al., 2021; Hendriks et al., 2017; Ooms-Evers et al., 2021).

This study aims to contribute to the existing literature by investigating the efficacy of an ITT program for adolescents using a mixed-method approach. What makes this study unique is the combination of analysing clinical data and youths' narratives. This approach is particularly suitable for understanding efficacy beyond clinical outcomes of PTSD symptomatology, hereby providing unique insights into the subjective experience of adolescents participating in ITT, and more specifically, how adolescents experience and make sense of changes in symptomatology and daily functioning. In terms of PTSD symptomatology, the hypothesis posited is that participation in ITT will reduce PTSD symptoms, aligning with prior results from studies on adult ITT programs and the first studies targeting ITT programs for youth.

Design and Setting

The study adopted a retrospective cohort design, utilizing a mixed-method approach to investigate the efficacy of ITT. The quantitative component encompassed pre- and post-treatment assessments of PTSD symptomatology, while the qualitative component involved narratives written by participating youth during treatment. The research transpired at Herlaarhof, a prominent community mental health center in the Netherlands specializing in severe psychiatric disorders among children and adolescents. Renowned for its expertise in PTSD and related disorders, Herlaarhof introduced a tailored 4-week ITT program in 2020. This program specifically targeted youth exposed to multiple traumas or those who did not benefit adequately from prior interventions. The ITT program amalgamated evidence-based therapies such as psycho-education, EMDR, imaginary exposure, and in-vivo exposure. Supplementary elements like family interventions, creative therapy, psychomotor therapy, and writing therapy were also integrated. The program adopted a therapist rotation model.

Participants

A total of 39 adolescents, aged between 12 and 21, participated in ITT at Herlaarhof from August 2020 to October 2022. Referrals to ITT were made by practitioners at Herlaarhof and other mental healthcare facilities. To qualify for ITT, participants needed to exhibit PTSD symptomatology and express motivation for short-term intensive treatment. ITT was not recommended in cases of immediate danger, where the source of trauma was ongoing. The study included only youth with a PTSD classifying diagnosis. Among the initial sample, 17 participants were excluded due to incomplete data (n = 15), absence of a PTSD diagnosis (n = 1), and unfinished treatment (n = 1). Consequently, the final analysis involved a sample of 22 participants (90.1% female, Mage = 17.0, SD = 1.72), with half of the sample providing consent for the analysis of their narratives, resulting in a final qualitative analysis sample of 11 youth.

Measures

CAPS-CA-5

A Dutch translation of the Clinician-Administered PTSD Scale for DSM-5 – Child/Adolescent Version (CAPS-CA DSM-5; Lindauer, 2019) was utilized to establish PTSD classification and symptom severity. CAPS-CA-5 is a validated semi-structured diagnostic interview that assesses PTSD symptoms following DSM-5 criteria. The interview includes a life-event checklist and 30 items targeting symptom frequency and severity. Results are summed to calculate total symptom severity (combining frequency and severity) and individual symptom cluster severity scores. PTSD classification is determined by assessing the "presence" or "absence" of each symptom, following the DSM-5 diagnostic rule. A symptom is considered present if the corresponding item severity score is rated 2 or higher.

Narratives

Participants, along with a trauma therapist, composed a short narrative using a provided form as a guide. The narrative covered relevant treatment goals, self-observations during treatment, and reflections on both the retrospective view of their treatment experience and their prospective outlook towards the future. The narrative form is part of Herlaarhof's clinical ITT program and was not specifically developed for research purposes.

Data collection

Pre- and post-test measures of PTSD classification and symptom severity occurred in the week before and five weeks after treatment, respectively. Youth narratives were collected in the week after treatment. All collected data were considered part of the ITT treatment protocol and were documented in the patient files. Results from CAPS DSM-5 were deemed anonymous data by the local ethical committee; hence, no informed consent was required for its use. Informed consent for the use of narratives was obtained through an information letter and consent form sent to all patients who received ITT. Practitioners also inquired whether patients gave consent to be contacted by the research team.

Data Analysis

Quantitative analysis involved paired samples T-tests to assess differences between pre- and post-test CAPS-CA 5 measures (total symptom severity scores and DSM-5 PTSD symptom cluster severity scores) and a chi-square test to assess changes in DSM-5 PTSD diagnosis. Qualitative analyses were conducted from a critical realist perspective, assuming that there is a reality to be investigated while recognizing that representations of this reality are influenced by the culture, language, and interests of the participant. Inductive thematic analysis, as described by Braun & Clarke (2006), was used, involving reading and rereading narrative transcripts, initial pattern identification, line-by-line coding, and checking for patterns of variability and consistency. Themes were identified at both the manifest and latent levels, based on the knowledge gained from assessing available trauma literature. Themes were refined until they formed a coherent pattern with the coded data, using the software program Atlas.ti.

Differences between pre- and post-test CAPS-CA 5 measures of total symptom severity and symptom cluster severity.

Paired samples t-tests were conducted to examine the disparities in CAPS-CA 5 total symptom severity and symptom cluster severity scores between the pre- and post-test assessments. The results indicated a significant reduction in total symptom severity scores for participants after treatment (M = 51.14, SD = 9.463), compared to before treatment (M = 34.18, SD = 17.933, t(21) = 5.005, p < .001). The effect size, measured by Cohen’s d, was d = 1.18, signifying a large effect.

Regarding symptom cluster severity, the findings revealed a siginificant difference between criterion B scores after treatment (M = 8.27, SD = 6.112) and before treatment (M = 14.27, SD = 3.089, t(21) = 4.767, p < .001), criterion C scores after treatment (M = 3.23, SD = 2.409) and before treatment (M = 5.77, SD = 1.510, t(21) = 4.506, p < .001), criterion D scores after treatment (M = 12.36, SD = 5.860) and before treatment (M = 18.09, SD = 4.196, t(21) = 4.713, p < .001), and criterion E scores after treatment (M = 10.45, SD = 5.829) and before treatment (M = 13.00, SD = 3.491, t(21) = 2.488, p = .021). The effect sizes for each criterion, as measured by Cohen’s d, were d = 1.24, d = 1.27, d = 1.12, and d = 0.53, respectively, indicating a large effect size for criterion B, C, and D, and a medium effect size for criterion E.

Changes in PTSD diagnostic status after treatment.

A chi-squared test was employed to assess differences in PTSD diagnostic status based on pre- and post-test CAPS-CA 5 measures. Results demonstrated a significant difference in PTSD diagnostic status after treatment, with 8 out of 22 participants (36.4%) no longer meeting the criteria for PTSD.

Themes from narratives

Qualitative analysis of narratives resulted in three themes: 'Negative thoughts and feelings at the core,' 'Sharing diminishes loneliness,' and 'Who am I?'

Negative thoughts and feelings at the core

Negative thoughts and feelings play a central role in the narratives of youth participating in ITT, influencing their PTSD symptomatology and daily functioning. The narratives delve into how emotions such as self-criticism, self-blame, and mistrust become compelling reasons for seeking ITT. The negative thoughts and feelings often lead them to feel anxious, prompting withdrawal from school and social activities. In contrast to the burden of shame, guilt, and mistrust, they express a desire "to feel normal again," "to pick up normal life," and "to enjoy life and have fun again." While these negative thoughts and feelings act as a motivator for seeking help, they also pose a significant obstacle, instilling doubts in the youths about their ability to successfully complete therapy. The uncertainty about what to expect from treatment intensifies their internal struggles. Questions like "Can I handle it?" and "What if it succeeds, what if it doesn’t succeed?" loom large in their minds. Upon entering therapy, they describe ITT as "intensive," "difficult," and "confronting." The process stirs up a range of emotions, including anger, anxiety, panic, and sadness, challenging their ability to regulate these intense feelings. Despite the emotional upheaval, they undergo a transformative experience, expressing that it was positive to encounter new emotions. Shame and guilt transform into feelings of an unfairness, and they find themselves better equipped to acknowledge, express, and regulate their emotions. However, the introduction of these 'new' emotions can also leave adolescents feeling overwhelmed or confused.

Sharing diminishes loneliness

Apart from the attitude to "just go for it," social support emerges as a crucial aspect influencing their decision to start, endure, and complete ITT. Friends, family, fellow patients, and ITT team members are perceived as valuable sources of support. The ability to share, ask questions, the presence of others, the offered distractions, and the opportunity to feel normal contribute to their sense of being supported. “It felt like they took me seriously”. Social support, however, involves a delicate balance. Parents, for example, walk a fine line between offering too much or too little support, which can be perceived as unwanted interference or neglect. Throughout the ITT process, youth gain insights into the significance of their social network, emphasizing the importance of sharing experiences: “the past is not gone, but talking about it helps” and “I feel less lonely when I share my story”. This increase in sharing fosters greater trust in themselves and their social network. Consequently, feeling supported is crucial for youth to actively engage in ITT, and the process of sharing in ITT reinforces their trust in the received support. This is evident in statements like "I share more with my parents" and "My trust in others has increased."

Who am I?

The narratives also highlight a pronounced quest for identity among youth undergoing ITT. While identity exploration is a natural part of their developmental phase, the experience of trauma shapes and complicates this quest. On one hand, the youth express a sense of pride upon completing therapy, realizing their capability to overcome challenges and move beyond avoidance. They assert, “I experienced that I am able to do this, that I can stop avoiding”, "I am a diehard" and "I am more than my trauma." On the other hand, there is a pervasive sense of confusion about their identity, especially after enduring trauma symptoms for an extended period. Questions such as "Who am I, now that I am not bothered by the trauma symptoms anymore?" underscore their insecurity about the newfound changes. Previously confined by anxiety, they now grapple with new emotions and thoughts, making it challenging to navigate their understanding of self. The struggle to handle these unfamiliar emotions prompts reflections on self-stability. “It was difficult to handle those emotions that I had not experienced before”, “All sorts of new questions came to mind”, “How can I understand myself better?”, “I didn’t feel stable”. It appears as if these adolescents need to forge a new identity for a life beyond trauma. Importantly, most adolescents express a desire to explore this theme further in psychotherapy post-ITT.

To date, limited research has explored the efficacy and applicability of ITT for youth. This study, involving a sample of 22 adolescents aged 12 to 21, aimed to assess changes in PTSD symptoms following participation in an ITT program. The primary hypothesis was that engagement in ITT would lead to a reduction in PTSD symptoms. Concurrently, the research sought to delve into the subjective experiences of adolescents undergoing ITT, specifically regarding their interpretation of changes in symptoms and daily functioning.

As expected, quantitative analyses revealed a statistically significant decrease in PTSD symptoms among participants in the ITT program. This reduction was evident in both the overall symptom severity and the severity of individual DSM-5 symptom clusters. The decline in PTSD symptoms resulted in a loss of PTSD classification among 36,4% of the sample. These results align with previous research on both adults (Voorendonk et al., 2020; Van Woudenberg et al., 2018; Foa et al., 2018) and adolescents (Ooms-Evers et al., 2021; Van Pelt et al., 2021; Hendriks et al., 2017). The observed percentage of classifying diagnosis loss post-treatment was comparatively on the lower end compared to earlier studies (Auren et al., 2022), however aligns with existing research suggesting a continued loss of PTSD classification over follow-up periods (Hendriks et al., 2017). Various other factors may contribute to differences in study outcomes as well. These include age (Hoogsteder, ten Thije, Schippers, & Stams 2021), comorbidity (Goldbeck, et al., 2016; Lewey et al., 2018), gender (Békés, 2016), therapist rotation (van Minnen, Hendriks, de Kleine, Hendriks, Verhagen, & de Jongh, 2018), number of sessions and treatment length (Deblinger et al., 2010), and structure and content of ITT programs (Hendriks et al., 2017; van Pelt et al., 2021).

Qualitative analyses uncovered themes shedding light on how adolescents perceive changes in PTSD symptoms during and after ITT. One prominent theme was the experience of negative thoughts and emotions at the outset and during treatment. These narratives illustrated the fear of handling or benefiting from ITT, potentially hindering treatment success. Intense and sometimes confusing emotions during and after treatment were reported, providing insight into why certain PTSD symptoms (e.g. arousal or restlessness) may persist post-treatment, but as confidence in recovery increases, continue to decline over time.

Social support emerged as a significant theme in understanding how adolescents experience and benefit from ITT. Social support is known to play a substantial role in enhancing mental health (Bauer et al., 2021), mitigating the consequences of trauma-induced disorders (Ozbay et al., 2007), and promoting treatment success and adherence (Spence et al., 2019; Fredette et al., 2016; Price et al., 2013) for both children and adults. Indeed, the study results highlight the positive impact of sharing narratives, demonstrating its potential to alleviate feelings of loneliness. This finding aligns with research conducted by Yasinski et al. (2016), which emphasized the significance of in-session caregiver behavior as a predictor of clinical outcomes for youth undergoing Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in various treatment phases. Therefore, incorporating social networks into ITT programs seems important. Future research endeavors can explore different methods and mechanisms through which social support impacts ITT treatment outcomes. Understanding these dynamics can contribute to refining and optimizing ITT interventions, ensuring they comprehensively address the multifaceted needs of adolescents recovering from trauma.

Identity confusion constituted a third significant theme within youths narratives. Considering that identity formation is a fundamental developmental milestone of adolescence (Erikson, 1959), it is noteworthy that this identity confusion may not necessarily diminish through ITT and may still demand attention post-treatment. Previous studies have demonstrated that childhood trauma can exacerbate identity confusion and have adverse effects on identity formation, leading to lower self-esteem, compromised daily functioning, and a diminished sense of identity (Berman et al., 2020; Waterman, 2020; Penner et al., 2019). Recognizing the relevance and potential impact of identity issues during adolescence, particularly among traumatized youth, ITT programs designed for adolescents could benefit from incorporating trauma-informed interventions that specifically reinforce developmental milestones. Such an approach would acknowledge the challenges youth face in their identity development and provide targeted support throughout the therapeutic process.

The study is subject to several limitations. Firstly, the retrospective design employed lacks a control group, impeding our ability to definitively attribute the observed results to the treatment itself rather than other contributing factors. Secondly, the study's relatively small sample size, coupled with a lack of gender diversity and underrepresentation of male participants, limits the generalizability of the findings. Notably, essential participant characteristics, such as the highest level of education and comorbidities, were not systematically collected during data collection, further restricting the study's applicability to broader populations. Thirdly, the narratives produced during the study may have been influenced by external factors, including the anticipation of sharing and the close interaction with a therapist during the writing process. These external influences could have prompted participants to introduce, alter, or omit specific details in their narratives, introducing a potential source of bias. Lastly, a potential bias may exist in the subgroup of participants who consented to the analysis of their narrative. A substantial group opted not to provide consent, raising uncertainties about whether the consenting subgroup is an adequate representation. These limitations underscore the need for caution when interpreting the study's findings.

Despite its limitations, the current study contributes a novel perspective to the still limited body of research on ITT for adolescents. The findings not only underscore the efficacy of ITT in reducing PTSD symptomatology but also offer unique insights into the lived experiences of youth undergoing ITT. Overall, these experiences highlight the potential advantages of systemic and developmentally sensitive interventions in ITT, acknowledging the distinct challenges and vulnerabilities faced by adolescents in the aftermath of trauma. In essence, the study emphasizes the significance of going beyond mere clinical symptom change. Recognizing the importance of a holistic approach that considers both clinical outcomes and the lived experiences of individuals is crucial for advancing the field and improving the overall well-being of traumatized youth.

Data sharing and declaration

This manuscript’s data will not be deposited.

Compliance with Ethical Standards

Conflict of interest The authors declare no competing interests.

Ethical approval This study was approved by the ethical review committee of Reinier van Arkel (CW02213)

Informed consent All participants of the qualitative study provided informed consent.

Funding No funding was received for conducting this study.

Author Contribution

EE conceived of the study, participated in its design and coordination, performed the qualitative analysis and drafted the manuscript; DB performed the statistical analysis and participated in drafting the manuscript; DF participated in the interpretation of the data and helped to draft the manuscript; FG participated in the design and coordination of the study, performed the measurement, performed the coding of interviews and helped to draft the manuscript. All authors read and approved the final manuscript.

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No competing interests reported.

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Making Sense of Change after Intensive Trauma Treatment; a Mixed- Method Study into Adolescents Experience of Efficacy

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Abstract

Introduction

Methods

Design and Setting

Participants

Measures

CAPS-CA-5

Narratives

Data collection

Data Analysis

Results

Themes from narratives

Negative thoughts and feelings at the core

Sharing diminishes loneliness

Who am I?

Discussion

Declarations

Author Contribution

References

Additional Declarations

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