The concept of complex posttraumatic stress disorder (CPTSD) was first proposed by Herman in 1992 (Herman, 1992), but it has only recently been introduced as an official diagnosis in classification guidelines, such as the World Health Organization's ICD-11. Therefore, it is not surprising that after more than 3 decades of lack of a structured definition of CPTSD, there is inconsistency in the treatments applied. There are generally 2 main psychological approaches;
- a 3-phase based protocol for stabilization, trauma memory processing and reintegration (Cloitre et al., 2012) or;
- Trauma-focused psychotherapy without stabilization.
Stabilization and trauma memory processing are probably relatively familiar to humans, and “reintegration” can be thought of as how to bring the new you into your everyday life (this is my simplified interpretation).
Karatzias, Murphy, and colleagues (2019) completed a systematic review and meta-analysis of psychological interventions for ICD-11 complex PTSD symptoms. However, all studies and analyzes have focused on either stabilization or trauma memory processing, and no publication has considered factoring in the reintegration phase. This dark corner of the knowledge forest also meant inconsistency with the definition of the stage of reintegration and a lack of evidence on what reintegration interventions might look like.
Condon et al. CPTSD chose to look at this anomaly within the evidence base, and what better way than to ask a number of expert international trauma clinicians for their views to help conceptualize the definition, composition, and key principles of delivery of reintegration.
There is no clear evidence for the reintegration phase of comprehensive PTSD treatment, that is, how to bring the new you into your daily life.
Methods
A number of experts have been identified as participants. To be eligible, they must have at least 10 years of clinical experience working with people with CPTSD and they must:
- a clinical or deputy clinical lead in a national specialist trauma service; and/or
- hold a senior position in a national or international trauma organization; and/or
- The widely leading clinical academic publication on CPTSD.
Each participant then completed an online semi-structured interview with 11 open-ended questions on definition, practical clinical use, composition, basic principles, and assessment of reintegration. The questions were designed based on previous literature on CPTSD and with an expert reference group of leading UK trauma clinicians.
Results
Sixteen leading experts were recruited to participate in the study:
- Specified Gender: Female (n=9), Male (n=7)
- Role: Clinical psychologist (n=4), Academic clinical psychologist (n=10), Psychiatrist (n=1), Counseling psychologist (n=1)
- Ethnicity: White (n=13), (White British (n=7), White European (n=1), White Other (n=5)), Mixed Other (n=1), Mixed White (n=1 ), Asia (n=1)
- Setting*: Public health service (n=10), University (n=10), Private practice (n=3), Charity (n=2)
- Geographic location: England (n=10), Scotland (n=1), Wales (n=1), Switzerland (n=1), USA (n=1), Chile (n=1), South Africa (n= 1) =1)
*Several participants worked in more than one setting, eg both university and public health service.
Interviews were transcribed verbatim and a thematic analysis of the Codebook was used (Brown & Clarke 2019) allowing the researchers to capture areas of consensus along with exceptions and disagreements.
Five main themes were identified deductively:
- Definition
- Reintegration cost
- Composition
- Basic principles
- Evaluation
Sub-themes were then constructed inductively:
Definition
There was considerable difference on this issue, with a shared acknowledgment of the problem of definition. Key topics discussed include: sense of identity/self, transfer of skills from therapy to life, future-oriented thinking, access to resources, and improving life and social strategies.
Reintegration cost
All experts recognized reintegration as an important part of treatment; adding invaluable life skills that can be used outside of therapy. Most experts thought of reintegration as something that empowers the individual, but also gives meaning to the entire course of therapy, and neglecting it can result in no change in symptom reduction.
Reintegration composition
There is considerable variation among experts on what constitutes reintegration, but they all agree that interventions should be tailored to the individual. Key examples are: performance improvement, social integration, physical well-being and exercise, occupation, emotion regulation, symbolic rituals, and group work.
Basic principles of reintegration
All experts emphasized that a people-centered approach is key, and that it should be collaborative and have realistic goals. There was no consensus on who should deliver it, but most experts agreed that the treating clinician should either initiate or lead reintegration treatment, but need not be the sole provider. Most participants believed that the work of reintegration should be initiated early in therapy, but with increasing emphasis throughout treatment. Participants had difficulty answering the general principle of how long reintegration should last, but at least 3 months to several years.
Evaluation of reintegration
Participants discussed quality of life, well-being, measures of global functioning, social adjustment scales, satisfaction, and goal-based outcome measures. Most experts recommend a combination of objective clinical measures and subjective patient-based measures.
The main expert consensus was that reintegration interventions should be person-centred and collaborative; evaluated by objective and subjective quality of life measures.
Results
The results of this study begin to clarify what a reintegration framework is/can be and how it can be used. The authors emphasized that the themes of identity, transfer of skills to real life, future orientation, access to resources and finally improving life are consistently addressed. However, there was far from a clear consensus on the definition and composition of reintegration, highlighting the need for more specific research on the role of reintegration in the treatment of CPTSD.
All experts recognized reintegration as an important part of treatment, but there were significant differences in definition and composition.
Strengths and limitations
There is a general lack of literature on this topic, and this appears to be the first study to seek expert opinion on reintegration interventions. The researchers intentionally included a range of participants from different settings, including a range of geographical locations, with the aim of comparing different clinical roles, similarities and differences of opinion between different client groups and clinical settings with CPTSD. was investigated. All interviews were conducted online and by the same researcher, limiting any specific variation or bias in the interview process. The use of a standardized coding measure also increased the reliability of the results.
However, this was a very small study with only 16 participants and only 4 of these were based outside the UK. This is a good start in terms of obtaining data for reintegration interventions, but more research is needed.
It was a small research oak, but it can grow into strong research oaks.
Implications for practice
In relation to clinical experience, there was a clear consensus that reintegration interventions are important in the treatment of CPTSD. Personally, as a psychiatrist, I was most familiar with the stabilization and trauma memory processing phases of treatment, and I struggle to recall psychological colleagues discussing the reintegration phase. If this paper can lead to increased awareness of this indispensable 3rd stage of treatment in clinical practice, then this is a good step forward for patients with CPTSD.
However, there are greater implications and opportunities for future research; Consensus on the definition, composition, delivery method and evaluation of reintegration interventions is still lacking. This feels like an area ripe for selection with randomized controlled trials. There could also be a qualitative arm for future research to help understand the nuances of the reintegration phase from the patient's perspective.
In conclusion, for patients with CPTSD, you may have to… Wait for a more detailed database on reintegration interventions.
Increasing awareness of reintegration interventions is one of the best outcomes of this paper for patients with Complex PTSD.
Statement of interest
There is no conflict of interest related to this study or publication.
Connections
Primary paper
Maria Condon, Michael AP Bloomfield, Helen Nicholls & Jo Billings (2023) Views of expert international trauma clinicians on the definition, composition and delivery of reintegration interventions for complex PTSD, European Journal of Psychotraumatology, 14:1,2165024 https://doi.org/10.1080/20008066.2023.2165024
Other references
Cloitre, M., Courtois, C., Ford, J., Green, B., Alexander, P., Briere, J., Herman, JL, Lanius, R., Stolbach, BC, Spinazzola, J., Van der Kolk, B. A., & Van der Hart, O. (2012). ISTSS expert consensus treatment guidelines for complex PTSD in adults. https://www.istss.org/ISTSS_Main/media/Documents/ISTSS-Expert-Concesnsus-Guidelines-for-Complex-PTSD-Updated-060315.pdf.
Herman, JL (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5(3), 377-391. https://doi.org/10.1002/jts.2490050305
Karatzias, T., Murphy, P., Cloitre, M., Bisson, J., Roberts, N., Shevlin, M., Hyland, P., Maercker, A., Ben-Ezra, M., Coventry, P. ., Mason-Roberts, S., Bradley, A., & Hutton, P. (2019). Psychological interventions for ICD-11 complex PTSD symptoms: A systematic review and meta-analysis. Psychological Medicine, 49(11), 1761-1775. https://doi.org/10.1017/S0033291719000436