Improving the provision of mental health care for survivors of psychological trauma
Submitting InstitutionEdinburgh Napier University
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Psychology and Cognitive Sciences: Psychology
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
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
Grants awarded in the census period in the area of psychological
K. Power, T. Karatzias (2013). Medically Unexplained Symptoms in People
with History of Psychological Trauma. National Strategy Funding, Scottish
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
"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
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 http://www.nice.org.uk/CG26,
e.g. p. 164
, p. 117, p. 100, p. 120
22nd April 2011 minutes
5,8NHS Lothian, The Rivers Centre, Tipperlinn House, Royal
Edinburgh Hospital, Edinburgh EH105BD.