The concept of complex post-traumatic stress disorder (CPTSD) was proposed by Herman in 1992 (Herman, 1992), but it has only recently been introduced as an official diagnosis in classification manuals eg ICD-11 World Health Organization. Therefore, in the absence of a structured definition of CPTSD for over 3 decades, it is not surprising that there is inconsistency in treatment methods. There are generally 2 main psychological approaches;

• a 3 step-based protocol of stabilization, trauma memory processing and reintegration (Cloitre et al., 2012) or;
• Trauma-focused psychotherapy without fixation.

Stabilization and trauma memory processing are very familiar to people and ‘reintegration’ can be considered how to bring new people into your daily life (this is my simple explanation).

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 reviews focused on consolidation or trauma memory processing, with no publications reviewed on the reintegration phase. This dark corner of the knowledge woodland means that there is inconsistency with the definition of the reintegration stage and a lack of evidence about what reintegration interventions might look like.

Condon et al. chose to look at this anomaly in the CPTSD evidence base and what better way than to ask a range of expert international trauma clinicians for their views to help conceptualise the definition, composition and key principles of the delivery of rehabilitation.

methods

A range of experts were identified as participants. To be included they must have at least 10 years of experience working clinically with people with CPTSD and they must be:

• Clinical or Deputy Clinical Lead in a National Specialist Trauma Service; and/or
• holding a senior position in a national or international trauma organization; and/or
• Widely popular clinical academic publication on CPTSD.

Each participant completed an online semi-structured interview consisting of 11 open-ended questions regarding definition, practical clinical use, composition, key principles, and evaluation of reintegration. Questions were developed based on prior literature on CPTSD and with an expert reference group of leading UK trauma clinicians.

Results

16 eminent experts were recruited to participate in the study:

• Identified 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), United States (n=1), Chile (n=1), South Africa (n= 1)

*Many participants worked in more than one setting, e.g. in the University and in the Public Health Service.

Interviews were transcribed verbatim and codebook thematic analysis was used (Braun & Clarke 2019) allowing the researchers to capture areas of consensus as well as exceptions and disagreements.

Five major themes were established deductively:

1. definition
2. The value of reunification
3. composition
4. Main principles
5. evaluation

Subthemes were established inductively:

definition

There is considerable variation on this theme with shared acknowledgment of the challenge of definition. Key topics discussed include: identity/self-concept, transferring skills from therapy to life, future-oriented thinking, accessing resources, life enhancement, and social strategies.

The value of reunification

All experts considered reintegration an important part of treatment; Adding invaluable transferable life skills that can be used outside of therapy. Many experts have reflected on reintegration as specifically empowering to the individual, but emphasizing the overall course of treatment and neglecting it will make no difference in symptom reduction.

Composition of reunification

Views about what constitutes reintegration vary considerably among experts, but they all agree that interventions should be tailored to the individual. Key examples include: performance enhancement, social integration, physical well-being and exercise, occupation, emotional regulation, symbolic rituals, and group work.

The main principles of reintegration

All the experts highlighted that a person-centred approach is key and should be collaborative and have realistic goals. There is no consensus on who should provide it, but most experts agree that the treating physician should initiate or lead reintegration therapy, but need not be the sole provider. Most participants believed that reintegration work should begin early in treatment, but with increasing emphasis throughout treatment. Participants struggled to answer how long the reunification should last, but the general formula was at least 3 months to several years.

Evaluation of reintegration

Participants discussed measuring quality of life, well-being, global functioning, social adjustment criteria, satisfaction, and goal-oriented outcome measures. Most experts recommend a combination of objective clinical measurement and subjective patient-based measures.

Conclusions

The results of this study begin to clarify what a framework for reintegration is/could be and how it can be used. The authors highlight that the themes of identity, transfer of skills to real life, being future-oriented, accessing resources and finally improving life are consistently discussed. However, there is no 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.

Strengths and limitations

There is a general paucity of literature on this topic and this is the first study to explore expert opinion regarding reintegration interventions. The researchers purposefully included a range of participants from a variety of settings, including diverse clinical roles, diverse client groups with CPTSD, and similarities and differences of opinion between clinical settings. examined. The interviews were all conducted online and by the same researcher limiting any specific variation or bias in the interview process. Using a standardized coding measure improved the validity of the results.

However, only 16 made it into this very small study and only 4 of these were outside the UK. This is a good start in terms of obtaining information for reintegration interventions, but further research is needed.

Implications for practice

Regarding clinical practice, there is a clear consensus that reintegration interventions are necessary when treating CPTSD. I personally, as a psychiatrist, am familiar with the stabilization and trauma memory processing phases of therapy and struggle to recall psychiatric colleagues discussing the reintegration phase. If this paper leads to increased awareness of this invaluable 3^RD This is a promising step forward for patients with CPTSD as a stage of treatment in clinical practice.

But there are huge implications and opportunities for future research; Consensus is still needed on the definition, composition, method of delivery and evaluation of reintegration interventions. This seems like an area ripe for picking with randomized controlled trials. Future research may also have a qualitative arm 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 knowledge base on reintegration interventions.

Declaration of Interests

There is no conflict of interest related to this study or publication.

Links

Primary paper

Maria Condon, Michael AP Bloomfield, Helen Nicholls & Joe Billings (2023) Complex PTSD, European Journal of Psychotraumatology, 14:1,2165020202020202020202000000000 14:1,216502002

Other references

Cloitre, M., Courtois, C., Ford, J., Green, B., Alexander, P., Briere, J., Herman, JL, Lanius, R., Stollbach, BC, Spinazola, J., van der Kolk, BA, & van der Hart, O. (2012). ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults.

Herman, JL (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5(3), 377–391.

Karatzias, T., Murphy, P., Cloitre, M., Bisson, J., Roberts, N., Shevlin, M., Hyland, P., Merker, 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.