Improving the provision of mental health care for survivors of psychological trauma

Submitting Institution

Edinburgh Napier University

Unit of Assessment

Allied Health Professions, Dentistry, Nursing and Pharmacy

Summary Impact Type


Research Subject Area(s)

Medical and Health Sciences: Public Health and Health Services
Psychology and Cognitive Sciences: Psychology

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Summary of the impact

Research at Edinburgh Napier University regarding psychosocial interventions for trauma has pioneered management of mental health problems. We have developed and tested a number of individual, group and self-help interventions aimed at promoting recovery following psychological childhood and adulthood trauma. We have trained a large number of healthcare professionals on our interventions in the voluntary and statutory sectors. Our research has also informed policy regarding the management of psychological trauma. Self-help materials developed through our research are currently being used by health and social care workers in Scotland and abroad, making an impact on the wellbeing of survivors of trauma.

Underpinning research

Post-Traumatic Stress Disorder (PTSD) is a debilitating condition, which follows exposure to adverse life events such as accidents and natural disasters. Depression and substance misuse are common comorbid to PTSD conditions. The research programme on PTSD and psychological trauma at Edinburgh Napier University was led by Professor Thanos Karatzias (Professor of Mental Health; 2008 — present, Professor Michael Brown (Professor of Health and Social Care, 2008 — present) and Dr Zoë Chouliara (Reader in Person Centred Care, April 2013 — present) in collaboration with colleagues from the National Health Service (NHS; Dr Anne Douglas, OBE — NHS Greater Glasgow and Clyde, Dr Sandra Ferguson — NHS Lothian) and other Higher Education Institutes (e.g. Professor Kevin Power Stirling University and NHS Tayside, Professor Keith Brown — Stirling University and NHS Forth Valley). The programme incorporated a series of studies that involved quantitative, qualitative and mixed methods approaches and aimed at developing and testing individual, group and self-help interventions for trauma survivors.

The National Institute for Health and Care Excellence (NICE) recommends psychological interventions for PTSD including Trauma Focused Cognitive Behavioural Therapy (TFCBT) or Eye Movement Desensitisation and Reprocessing (EMDR). Karatzias and Chouliara, with a multi-professional group of nurses, psychologists and psychiatrists, have been involved in the only two trials in Scotland determining the effectiveness and acceptability of these interventions for PTSD, which have shown that both treatments are effective in Scottish community samples3,1-3,3. In order to standardise new interventions with allegedly rapid response, we compared EMDR against a novel intervention for PTSD namely Emotional Freedom Techniques (EFT). Although EFT is being used routinely for the treatment of PTSD internationally, this was the first ever trial on the effectiveness of EFT for PTSD. Our results indicated that EFT is equally effective and acceptable as EMDR3,3. EFT and EMDR require limited communication skills and, therefore, can be used with people with communication difficulties, such as people with learning disabilities. Karatzias, Brown and Chouliara are currently conducting the first ever trial in the United Kingdom (UK) on the effectiveness of EMDR for people with learning disabilities and history of psychological trauma.

Nevertheless, interventions such as EFT and EMDR are not appropriate for survivors of childhood adverse life events. Karatzias and Chouliara have been involved in the development and preliminary testing of "Survive and Thrive" (S&T) in a controlled investigation, which is a protocol-based intervention for the mental health and behavioural problems of survivors of childhood trauma. Preliminary results indicate that the intervention may be useful for helping survivors to stay safe (e.g. reduce self-harm) in preparation for individual therapy3,4.

The evidence base on the patient perspective of the experience of psychological trauma, treatment and recovery is limited. Understanding this experience is paramount to increasing adherence and patient satisfaction. Chouliara and Karatzias, using qualitative methodology, have led the development of the first ever recovery model which demonstrates the steps that trauma survivors follow to improve their well being3,5. The model informed the first ever self-help recovery booklet for survivors of childhood sexual abuse: "Acts of Recovery".

References to the research

Since 2008, our research on psychological trauma has resulted in nine published papers (four more submitted) and seven conference presentations. In total, the trauma work at Edinburgh Napier University was awarded seven grants worth £516,705 and three knowledge transfer projects £22,736.

References to section 2

3,1Power, K.; McGoldrick, T.; Brown, K.; Buchanan, R.; Sharp, D.; Swanson, V.; Karatzias T. (2002). A Controlled Comparison of Eye Movement Desensitisation and Reprocessing versus Exposure plus Cognitive Restructuring versus Waiting List in the Treatment of Post-Traumatic Stress Disorder. Clinical Psychology and Psychotherapy, 9, 299 - 318.


3,2Karatzias, T.; Power, K.; McGoldrick, T.; Brown, K.; Buchanan, R.; Sharp, D.; Swanson V. (2007). Predicting Treatment Outcome on Three Measures for Post-Traumatic Stress Disorder. European Archives of Psychiatry and Clinical Neuroscience, 257, 40 - 46.


3,3Karatzias, T.; Power, K.; Brown, K.; McGoldrick, T.; Begum, M.; Young, J.; Loughran, P.; Chouliara, Z.; Adams. S. (2011). A Controlled Comparison of the Effectiveness and Efficiency of Two Psychological Therapies for Post Traumatic Stress Disorder (PTSD): Emotional Freedom Techniques (EFT) vs. Eye Movement Desensitisation and Reprocessing (EMDR). Journal of Nervous and Mental Disease, 199, 372 - 378.


3,4Ball, S.; Karatzias. T.; Mahoney, A.; Ferguson, S.; Pate. K. Interpersonal Trauma in Female Offenders: A New, Brief, Psycho-educational Intervention Delivered in a Community Based Setting. Forensic Psychology and Psychiatry, in press.


3,5Chouliara, Z.; Karatzias, T.; Gullone, A. (2013). Experiences of Recovering from Childhood Sexual Abuse: The Perspective of Adult Survivors. Journal of Psychiatric and Mental Health Nursing, in press.


Grants awarded in the census period in the area of psychological trauma

K. Power, T. Karatzias (2013). Medically Unexplained Symptoms in People with History of Psychological Trauma. National Strategy Funding, Scottish Government (£51,116).

T. Karatzias, A. Mahoney (2013). Psychoeducation vs. Waiting List Control for Complex Trauma in Female Offenders. National Strategy Funding, Scottish Government (£45,211).

T. Karatzias (PI), M. Brown, Z. Chouliara, S. Ferguson, L. Taggart, D. Patterson, K. Nankervis (2012). Psychological Trauma in People with Learning Disabilities: Service Provision and Service Development. Same as You, Scottish Government (£280,000).

T. Karatzias (PI), S. Ferguson, Z. Chouliara, K. Cosgrove (2011). Effectiveness and Acceptability of Group Psychotherapy Based on the Trauma, Recovery and Empowerment Model (TREM). Gender Based Violence, Scottish Government (£70,000).

Z. Chouliara, T. Karatzias, S. Ferguson, F. McAfee (2010). Pathways to Recovery from Childhood Sexual Abuse (CSA). National Strategy Funding, Scottish Government (£48,760).

T. Karatzias (PI), S. Ferguson, K. Cosgrove, Z. Chouliara, C. Jackson, A. Douglas (2008). Development and Effectiveness of a Group Psychoeducational Support Intervention for Adult Survivors of Childhood Sexual Abuse (CSA). NHS Lothian, NHS Greater Glasgow and Clyde, NHS Lanarkshire, Lanarkshire GBV Training Consortium, Scottish Government (£50,400).

T. Karatzias (PI), A. Macdonald, Z. Chouliara, A. Karczewska-Slowikowska, N. Frazer, J. MacArthur, C. Hutchison (2008). Psychotherapy Services for Adult Survivors of Childhood Sexual Abuse (CSA) in Lothian: Therapists' and Service Users' Perspectives. CSO funded NHS Lothian Health Services Research Programme (£19,978).

Details of the impact

Our work on psychological trauma is developmental and extends beyond the Research Excellence Framework assessment period. It has impacted policy, mental health guidelines, practitioner training, professional practice and patient health, with national and international reach.

Informing policy and engagement with stakeholders and policy makers

The evidence we have produced on the effectiveness and acceptability of interventions for psychological trauma has informed clinical guidelines for the treatment of trauma-related conditions. Our first trial on the effectiveness of TFCBT vs. EMDR3,1 has been cited by NICE (2005) guidelines for the treatment of PTSD5,1. The NICE guidelines have informed the 2011 guidelines regarding the delivery of evidence-based psychological interventions in Scotland for trauma and complex trauma led by NHS Education for Scotland (NES). S&T is a Phase I intervention as recommended for the treatment of complex trauma in the Matrix. Prof. Karatzias was invited to be involved in the development of the Matrix for trauma and complex trauma5,2.

Because of his expertise in the area of psychological trauma, and as the Chair of the British Psychological Society Working Party for Survivors of Sexual Abuse (BPSSS), Prof. Karatzias was invited to join the National Reference Group for SurvivorScotland (2010 - 2012)5,3. The remit of the group was to develop a national strategy (i.e. SurvivorScotland) for survivors of sexual abuse in Scotland. Some of our work on psychological trauma has been funded directly by SurvivorScotland (see section 3, grants). Because of his expertise in childhood trauma, Prof. Karatzias has been asked to consult and advise the Scottish Government on a number of occasions. As an example, in 2011, Prof. Karatzias led the evaluation of the In-Care Service, the only Scottish national service for survivors of child sexual abuse5,4.

Impacts on healthcare practitioners, stakeholders and trauma survivors

We have conducted the first ever trial on EFT and have provided evidence to the international community that this is an effective, acceptable and safe intervention for PTSD. Unlike other established treatments for PTSD, such as TFCBT, EFT requires limited cognitive ability and, therefore, can be used with people with cognitive impairments including those with learning difficulties and disabilities. By demonstrating the benefits of this new intervention, a large number of vulnerable people with PTSD will profit.

"Acts of Recovery" has been endorsed by the Scottish Recovery Network (SRN) from 2012, a national initiative aiming to raise awareness of recovery from mental health problems, which can be downloaded for free by healthcare professionals and survivors from their website5,5. Mr Simon Bradstreet, Director of the SRN, said about "Acts of Recovery":

"Excellent resource — very clear and engaging content and well designed which always helps".

We are aware that the resource is being used in the UK and abroad, and we have received written feedback for this from colleagues in the UK and abroad (e.g. Australia). For example, Dr Alison Souter, Manager Regional Psychological Services, Ashfield, Australia said:

"Thanks for a great booklet. I can see that some sections, especially chapters 2 and 6 are a great resource for psychologists to use in preparing young people for leaving care together with "Survive and Thrive"

The following quote was provided by Dr Sue Waring, Head of Adult Mental Health in NHS Highland.

"I shared this with the group I'm running this afternoon and it had quite an impact on them... They all felt it was very relevant and really was something they could connect with. Job well done"

Because of its popularity, an easy-read version for people with communication difficulties, such as people with learning disabilities was also developed, in April 2013, and used across NHS areas in Scotland and beyond. It is also available on-line from a number of third sector organisations such as Rape Crisis5,6.

In 2010, Karatzias was invited to Chair the BPSSS with members from NHS Psychological Therapies Services and academics with an interest in this area. Dr Chouliara is the lead researcher for this group. In partnership with SurvivorScotland, the Scottish Government Strategy for Survivors of Sexual Abuse, the Working Party aims to raise awareness on prevalence and consequences of child sexual abuse and support relevant work in the areas of services, training and research on issues affecting survivors of sexual abuse. In 2011, BPSSS and Edinburgh Napier University hosted an event with key stakeholders from Scotland to discuss the management of traumatic conditions in survivors of trauma. More than 100 health and social care professionals from statutory and voluntary services attended the event at which our research on psychological interventions for childhood trauma was presented and discussed5,7.

The interventions we have developed for psychological trauma have been applied to practice by multi-professional teams including nurse therapists, psychologists, counsellors, therapists and psychiatrists and have improved the management of mental health conditions in trauma survivors. Since 2011, more than 162 survivors have been treated with S&T. The following quote was provided by one of them:

"Thank you so much, I have taken away so much from my sessions on a Tuesday afternoon". Another survivor also said after session 8: "Thank you for all of your help, I have benefitted from your help".

Since 2011, more than 50 therapists have been trained on S&T and now deliver the interventions across Scotland5,8. NES has sponsored training of health professionals on the delivery of S&T across NHS areas in Scotland. An evaluation was conducted of this training and rated very highly by healthcare professionals. It was concluded that:

The embedding of Survive and Thrive will help increase capacity within the trauma informed services of NHS Scotland, offering psycho-education to people who do not wish or require an individualised psychological intervention (NES / BPS, 23/10/2012)5,8.

Sources to corroborate the impact

5,1CG 26, e.g. p. 164

5,2 , p. 117, p. 100, p. 120

5,3 22nd April 2011 minutes




5,7 and

5,8NHS Lothian, The Rivers Centre, Tipperlinn House, Royal Edinburgh Hospital, Edinburgh EH105BD.