Psychosis

Psychological, Social and Integrative Approaches

ISSN: 1752-2439 (Print) 1752-2447 (Online) Journal homepage: http://www.tandfonline.com/loi/rpsy20

Psychological interventions for trauma in

individuals who have psychosis: A systematic
review and meta-analysis

Jacqueline Sin & Debbie Spain

To cite this article: Jacqueline Sin & Debbie Spain (2016): Psychological interventions for
trauma in individuals who have psychosis: A systematic review and meta-analysis, Psychosis,
DOI: 10.1080/17522439.2016.1167946

To link to this article: http://dx.doi.org/10.1080/17522439.2016.1167946

Published online: 23 May 2016.

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 Psychosis, 2016
http://dx.doi.org/10.1080/17522439.2016.1167946

Psychological interventions for trauma in individuals who have

psychosis: A systematic review and meta-analysis
Jacqueline Sina,b* and Debbie Spainc
a
NIHR Post Doctoral Research Fellow Population Health Research Institute St George’s,
University of London, London, England; bKing’s College London Prize Fellowship – NIHR
BRC Clinical Lecturer Health Service & Population Research Department, Institute of
Psychiatry, Psychology & Neuroscience, King’s College London, London, England; cNIHR
Clinical Doctoral Research Fellow MRC Social, Genetic and Developmental Psychiatry
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Centre Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London,
England
(Received 28 October 2015; accepted 15 March 2016)

Background: Psychological interventions, in particular those derived from cog-

nitive-behavioural therapy frameworks, and eye movement desensitisation and
reprocessing, are effective for reducing post-traumatic stress disorder and associ-
ated distress. To date, studies have tended to exclude individuals who have psy-
chosis; a clinical population who are known to be at risk of experiencing trauma.
Whether people with psychosis also benefit from trauma-focussed psychological
therapies (TFPT) warrants further investigation.
Method: A systematic search for randomised controlled trials was undertaken.
Data were synthesised using narrative and meta-analytic approaches.
Results: Five studies met the review inclusion criteria. Study findings overall
indicate that TFPT are effective for reducing intrusive thoughts and images, neg-
ative beliefs associated with traumatic memories, hypervigilance, and avoidance.
Limited data were available about the utility of interventions for improving
mood, anxiety and quality of life. Attrition rates were comparable for partici-
pants offered active and control conditions.
Conclusion: Findings are consistent with those reported for the non-psychosis
population. Future studies should establish which interventions are more accept-
able and glean more favourable outcomes for this clinical population.
Keywords: psychosis; post-traumatic stress disorder; PTSD; trauma; psychologi-
cal interventions; EMDR; systematic review

Introduction
Post-traumatic stress disorder (PTSD) is a mental health condition which can
develop as a result of witnessing, or experiencing, single or multiple traumatic
events, incurring a perceived threat to life or significant risk to physical well-being,
and intense fear, horror or helplessness (APA, 2013). DSM-5 (APA, 2013) outlines
four distinct symptom clusters, as follows: re-experiencing (for example, intrusive
thoughts/images related to the trauma); avoidance (for example, sites or cues associ-
ated with the traumatic event); arousal or hypervigilance (for example, “fight or
flight” responses, or panic symptoms); and negative thoughts and beliefs.

*Corresponding author. Email: Jacqueline.sin@kcl.ac.uk

© 2016 Informa UK Limited, trading as Taylor & Francis Group

 2 J. Sin and D. Spain

PTSD prevalence estimates are reported to fall between 0.4% and 3.5%
(Bisson, Roberts, Andrew, Cooper, & Lewis, 2013; Kessler, Sonnega, Bromet,
Hughes, & Nelson, 1995; NICE, 2005). Some populations, however, are at
increased risk of experiencing trauma and adversity, in particular, people who
have psychosis (Bebbington et al., 2011; Fisher et al., 2013; Morrison, Frame,
& Larkin, 2003; Read, Fink, Rudegeair, Felitti, & Whitfield, 2008). Approxi-
mately 30% of people with psychosis present with full-blown PTSD symptoms
or sub-threshold diagnostic presentations (Kilcommons & Morrison, 2005; NICE,
2014). Data from cross-sectional and longitudinal studies indicate that some
social factors may predispose individuals to developing both psychosis and
PTSD (Read et al., 2008). These include traumatic events occurring during
childhood, such as abuse or sustained bullying (Bebbington et al., 2011; Cun-
ningham, Hoy, & Shannon, 2016); and adulthood, such as vulnerability to
exploitation and victimisation (Kilcommons & Morrison, 2005; Mueser, Lu,
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Rosenberg, & Wolfe, 2010). Additionally, several studies have concluded that
positive psychotic symptoms, such as persecutory delusions, can also understand-
ably be perceived as traumatic (Jackson et al., 2009; Mueser et al., 2010). The
combination of psychotic symptoms and PTSD likely results in an exacerbation
of low mood and anxiety, functional impairment and reduced quality of life
(Mueser, Rosenberg, & Rosenberg, 2009; Read et al., 2008).
UK and Australian Clinical Guidelines pertaining to adults experiencing
single-event trauma (ACPMH, 2013; NICE, 2005, 2013) recommend a course of
8–12 individual outpatient sessions of trauma-focused cognitive behavioural
therapy (TFCBT including prolonged exposure), and/or eye movement desensiti-
sation and reprocessing (EMDR). TFCBT and EMDR, referred to as “trauma-
focused psychological therapies” (TFPT) share several commonalities: both
treatments encourage individuals to make sense of and process traumatic memo-
ries, beliefs and attributions about traumatic events and their impact; and
develop more effective strategies for ameliorating symptoms (Bisson et al.,
2013; Schnyder et al., 2015).
To date, empirical studies investigating the effectiveness and acceptability of
TFPT have often excluded individuals with a concurrent diagnosis of psychosis
(Mueser et al., 2010; NICE, 2014). This may be due to: diagnostic overshadow-
ing (Calvert, Larkin, & Jellicoe-Jones, 2008), concerns about engagement and
attrition (Callcott, Standart, & Turkington, 2004), or worry that interventions
may exacerbate psychotic symptoms (Gairns, Alvarez-Jimenez, Hulbert,
McGorry, & Bendall, 2015). Relatively little is known about the effectiveness of
TFPT for individuals with psychosis, although considerable evidence indicates
that CBT and psychosocial interventions can reduce psychotic symptoms, dis-
tress, and comorbidities, such as depression and anxiety (NICE, 2014; Turking-
ton, Kingdon, & Turner, 2002). Importantly, rates of adverse effects are not
increased for this group (NICE, 2014).
This review had three aims: (1) to synthesise evidence about the effectiveness of
TFPT for individuals with psychosis who have PTSD or symptoms of trauma; (2) to
establish whether any one intervention is more effective; and (3) to outline implica-
tions for clinical practice and research. Outcomes of interests were identified a priori
as follows: PTSD symptoms; quality of life; mental health symptoms; and adverse
events.
 Psychosis 3

Method
We have previously published a protocol in the Cochrane Library of Systematic
Reviews (see Sin, Spain, Furuta, Murrells, & Norman, 2015). This protocol served
as a basis for the present review, although we broadened the remit to include
individuals experiencing trauma in the absence of a PTSD diagnosis. The review
process followed PRISMA guidelines (Moher, Liberati, Tetzlaff, & Altman, 2009).

Search strategy
We searched the Cochrane Schizophrenia Group (CSG)’s study-based register of
controlled trials (CENTRAL) – compiled from systematic searches of medical and
social sciences databases (including AMED, EMBASE, MEDLINE, PsycINFO and
PubMed), clinical trials registers and sources of grey literature – using the following
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terms: (*trauma* or *ptsd*):ti,ab,kw of REFERENCE or (*trauma* or *ptsd*):sco

of STUDY, from the date of inception until 28 September 2015. Reference lists of
included studies were also reviewed, and corresponding authors of studies screened
were contacted for information regarding unpublished data and ongoing trials.

Inclusion and exclusion criteria

No language or publication sources limits were imposed. The inclusion criteria were
as follows: (1) randomised controlled trials (RCTs); (2) investigating TFPT for
PTSD, traumatic experiences, and/or the impact of these; (3) in adolescents or adults
with a diagnosis of a non-organic psychotic disorder, including schizophrenia, psy-
chosis, schizoaffective disorder and type 1 bipolar disorder; and (4) treated in any
setting. Studies which recruited individuals diagnosed with a range of mental health
disorders, a proportion of whom had psychosis, were included if either 50% of the
sample had psychosis or when subgroup data were available. We excluded interven-
tion studies where no specific outcome data pertaining to trauma were reported.

Data analysis
Data were analysed using narrative and meta-analytic approaches (see Sin et al.,
2015). Interventions were categorised into four main therapeutic approaches, as
described by Bisson et al. (2013): individual TFCBT; group TFCBT; EMDR; and
other psychological interventions not fitting into the above categories but which
were clearly trauma-focused in their aims and remit. Separate analyses were under-
taken to compare therapeutic approaches with inactive control conditions; when suf-
ficient data were available, a head-to-head comparison was conducted between
different interventions or active controls.

Results
Study selection and search results
Figure 1 outlines the search process and study selection. The search initially yielded
35 unique titles and abstracts. After examination, two duplicates were removed and
two additional references were identified by contacting trial authors and reviewing
trials registers. Eighteen references were excluded as their titles and abstracts were
 4 J. Sin and D. Spain
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Figure 1. PRISMA flowchart.

clearly irrelevant. Eight studies described in 17 references were assessed for eligibil-
ity. Three references were excluded following full-text examination, as one study
did not employ an RCT design (de Bont, van Minnen, & de Jongh, 2013); one did
not provide trauma-related outcome data (Penn et al., 2011); and one related to an
ongoing trial (Marlow, 2015, personal communication).

Overview of studies
Five studies, comprising 366 participants, met the review inclusion criteria (van den
Berg et al., 2015; Jackson et al., 2009; Mueser et al., 2008, 2015; Steel, 2010).
 Psychosis 5

(See Table 1.) Studies were undertaken in the UK (Jackson et al., 2009; Steel,
2010), the Netherlands (van den Berg et al., 2015) and North America (Mueser
et al., 2008, 2015). Two studies investigated the effectiveness of TFCBT compared
with usual care, using the same treatment protocol (Mueser et al., 2008; Steel,
2010), one compared TFCBT with psychoeducation (Mueser et al., 2015), one
investigated EMDR compared with prolonged exposure and a waitlist control (van
den Berg et al., 2015), and one evaluated a cognitive therapy-based intervention
(cognitive recovery intervention, CRI) compared with usual care for people experi-
encing first-episode psychosis (FEP) (Jackson et al., 2009).

Quality assessment of studies

Each study was independently assessed for risk of bias, according to criteria
described in the Cochrane Handbook for Systematic Reviews of Interventions
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(Higgins & Green, 2011). See Figure 2. The trial designs and conduct were
generally clearly reported, albeit that one study is as yet unpublished (Steel, 2015,
personal communication). Of note, failure to recruit in one study (n = 66 (27% of
320 planned), Jackson et al., 2009) meant that trial analysis was significantly under-
powered.

Trauma symptoms
Four studies included adults with a diagnosis of PTSD (n = 300) (van den Berg
et al., 2015; Mueser et al., 2008, 2015; Steel, 2010), confirmed with the clinician-ad-
ministered PTSD scale (CAPS by Blake et al., 1995). Jackson and colleagues
(2009) used the Impact of Event scale (IES by Sundin & Horowitz, 2002) to mea-
sure post-traumatic phenomena in relation to FEP.
In two studies, it was reported that most participants had experienced multiple
childhood traumas, including sexual, emotional and physical abuse (van den Berg
et al., 2015; Mueser et al., 2008). van den Berg and colleagues also identified that
28 participants (18% of the sample) developed PTSD as a consequence of traumatic
psychosis experiences. Two studies did not describe the nature of traumatic events
in detail (Mueser et al., 2015; Steel, 2010).

TFPT modalities
Across studies, four manualised TFPTs were delivered, on an individual basis. Three
studies (Mueser et al., 2008, 2015; Steel, 2010) investigated the effectiveness of
TFCBT based on cognitive models of PTSD (Ehlers, Clark, Hackmann, McManus,
& Fennell, 2005; Horowitz, Wilner, & Alvarez, 1979). The intervention comprised
psychoeducation about PTSD; breathing exercises; exposure-based sessions; and
cognitive restructuring. Treatment was offered for 12–16 sessions, and participants
were required to attend six or more sessions. One study (van den Berg et al., 2015)
tested the effectiveness of an eight-session prolonged exposure therapy (PE), based
upon an existing PTSD protocol (Foa, Hembree, & Rothbaum, 2007), comprising
case conceptualisation, and imaginal and in vivo exposure to a hierachy of trauma-
related situations and cues. Jackson and colleagues (2009) investigated the utility of
CRI, designed to enhance coping and adjustment following a FEP (which was
deemed to be the index traumatic experience), and reduce the impact and distress
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Table 1. Summary of included studies.

Study Participants Interventions Outcomes Results
Jackson Total n = 66 CRI (n = 36) vs. Trauma: IES CRI participants had marginally better scores on the
et al., Male = 74% TAU (n = 30) Mood/anxiety: IES compared to controls; this finding held true at 6-
2009 Mean age = 23.3, CDSS month follow up for participants who had high pre-
UK SD = 4.6 Self-esteem: SCQ treatment trauma symptoms
Ethnicity: 73% No significant differences between groups on the
Caucasian; 5% Black; CDSS and SCQ
J. Sin and D. Spain

15% South Asian; 7% Similar rates of attrition between groups; total

Mixed race attrition rates at 12-month follow up were 32%
Mueser Psychosis subsample TFCBT (n = 10) vs. Trauma: CAPS; No significant differences between groups for all
et al., n = 17* (demographic TAU (n = 7) PTCI outcomes
2008* data unavailable) Mood/anxiety: Loss to follow up was similar for both groups; total
USA Total study n = 108** BDI-II; BAI attrition rates between groups at 12-month follow up
Male = 21% Psychotic were 47%
Mean age = 44.2, symptoms: BPRS
SD = 10.6 Functioning: SF-
Ethnicity: 84% 12
Caucasian; 16% other
Mueser Psychosis subsample TFCBT (n = 32) vs. Trauma: CAPS; No significant differences between groups for all
et al., n = 67* BPPP (n = 35) PTCI outcomes
2015* Male = 39%, Mood/anxiety: Comparable attrition rates for both groups; total
USA Mean age = 43.4, BDI-II; BAI attrition rates at 18-month follow up were 28%
SD = 12.0 Psychotic
Ethnicity: 21% symptoms:
Caucasian; 15% PANSS
Hispanic; 64% non- Functioning:
White GAF; CAPS-
(Total study n=201**) social functioning
subscale
Quality of life:
QoLI

(Continued)
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Table 1. (Continued).
Study Participants Interventions Outcomes Results
Steel, Total n = 61* TFCBT (n = 30) vs. Trauma: CAPS; No significant differences between groups for all
2010* No demographic data TAU (n = 31) PTCI outcomes
UK available Mood/anxiety: Similar rates of attrition across groups was similar;
BDI-II; BAI total attrition rates were 23%
Psychotic
symptoms:
PANSS;
PSYRATS
Functioning:
GAF
Quality of life:
QOLS
van den Total n = 155 PE (n = 53) vs. Trauma: CAPS; PE and EMDR participants had fewer PTSD
Berg Male = 46% EMDR (n = 55) vs. PSS-SR; PTCI symptoms compared to controls post-intervention, as
et al., Mean age = 41.2, TAU (waitlist) Severe adverse measured by the CAPS, PSS-SR and PTCI
2015 SD = 10.5 (n = 47) events PE and EMDR participants were statistically more
Netherlands Nationality: 63% Dutch; likely to achieve loss of PTSD diagnosis compared
31% non-Western; 6% to controls, measured post-intervention and at 9-
Western, not Dutch month follow up
PE participants were more likely to gain full
remission from PTSD
Comparable rates of severe adverse events between
groups: 1 in PE; 2 in EMDR; and 4 in waitlist
Comparable rates of attrition between groups; total
attrition rates at 9-month follow up were 17%
*
Unpublished data, including subgroup sample, were obtained from the first author;
**
total original sample size and characteristics reported by the paper; TAU, treatment as usual; CRI, cognitive recovery intervention; IES, impact of events scale; CDSS,
Calgary depression scale; SCQ, Robson self esteem questionnaire; CAPS, clinician-administered PTSD; PTCI, post-traumatic cognitions inventory; BDI, Beck depression
inventory-II; BAI, Beck anxiety inventory; BPRS, expanded version of the brief psychiatric rating scale; SF-12, 12-Item short form survey; PANSS, positive and negative
syndrome scale; GAF, global assessment of functioning scale; QOLI, brief quality of life interview; PSYRATS, psychotic symptom rating scale; QOLS, quality of life
Psychosis

scale; PE, prolonged exposure; EMDR, eye movement desensitisation and reprocessing; PSS-SR, posttraumatic stress symptom scale self report.
7
 8 J. Sin and D. Spain
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Figure 2. Assessment of risk of bias.

associated with this. Participants were offered a maximum of 26 sessions, which
involved three main facets: engagement and formulation; trauma processing; and
appraisal of psychotic symptoms and experiences. An eight-weekly 90-minute
EMDR intervention, based on a Dutch translation of the standard EMDR protocol
(de Jongh & ten Broeke, 2003; Shapiro, 2001) was evaluated against TFCBT and
waitlist control in the study based in the Netherlands (van den Berg et al., 2015).
The intervention involved case formulation, identification of a hierarchy of traumatic
experiences, and bilateral eye movements which were applied as the dual-attention
stimuli to aid processing of traumatic memories. Lastly, one study (Mueser et al.,
2015) offered a three-session PTSD psychoeducation intervention, adapted from one
used in a previous study about severe mental illness (SMI) and PTSD (Pratt et al.,
2005), which included discussion about the causes and nature of PTSD, breathing
exercises and anxiety management.

Intervention effectiveness
Following statistical advice, we used a fixed-effect model for meta-analyses, given
the small number of studies (using RevMan 5.3) (Higgins & Green, 2011;
 Psychosis 9

Kontopantelis, Springate, & Reeves, 2013). We examined five comparisons: TFCBT

versus usual care/waitlist; EMDR versus waitlist; EMDR versus TFCBT; PTSD psy-
choeducation versus TFCBT; and CRI versus usual care.

TFCBT versus usual care/waitlist

Three studies investigated the effectiveness of TFCBT (n = 160) (van den Berg
et al., 2015; Mueser et al., 2008; Steel, 2010). Measures of treatment effect were cal-
culated for CAPS (Blake et al., 1995; Weathers, Keane, & Davidson, 2001), and
self-reported trauma-related cognitions (measured by the post-traumatic cognitions
inventory (PTCI; Foa, Ehlers, Clark, Tolin, & Orsillo, 1999). There was moderate
quality evidence that TFCBT was associated with improved outcomes compared
with usual care or waitlist groups, in terms of reducing CAPS scores (mean differ-
ence (MD) –13.78, 95% confidence interval (CI) = –23.67 to –3.89), as well as
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PTCI scores (MD –19.46, 95% CI = –35.05 to –3.88) post-intervention, and at

three- to six-month follow up (see Figure 3a). Meta-analyses of pooled data from
two studies (n = 113) (van den Berg et al., 2015; Mueser et al., 2008) provided some
evidence that TFCBT was more effective in reducing PTSD symptoms to the extent
that participants no longer met diagnostic criteria in the short and medium term
(Risk Ratio (RR) 1.76, 95% CI = 1.13 to 2.76) (see Figure 3b). As only one study
provided data on outcomes of participants’ self-reported PTSD symptoms, and full
remission from PTSD (van den Berg, 2015), meta-analysis was precluded. Nonethe-
less, there is some limited evidence favouring TFCBT on these two outcomes com-
pared to a waitlist control.
It was not possible to pool data for mental health and well-being outcomes: it
was not clear whether TFCBT gleaned more favourable outcomes, compared with
inactive controls.
One study provided data about rates of adverse events, and there were no differ-
ences between the two groups (van den Berg et al., 2015).

EMDR versus waitlist

One study compared EMDR with TFCBT and a waitlist control (van den Berg
et al., 2015). Meta-analysis was precluded. However, compared to the waitlist group
(n = 102), EMDR was more effective in reducing clinician-rated (CAPS) and self-re-
ported PTSD symptoms (PTCI and post-traumatic stress symptom scale self-report
(PSS-SR) by Foa, Riggs, Dancu, & Rothbaum, 1993). A statistically significant
number of participants receiving EMDR attained subthreshold PTSD symptoms (i.e.
loss of PTSD diagnosis) post-treatment and at six-month follow up. There were no
significant differences, between groups, in terms of rates of unspecified adverse
events and loss to follow up.

EMDR versus TFCBT

When comparing EMDR with TFCBT (n = 108), participants in both groups derived
comparable benefits in self-rated and clinician-administered PTSD outcome mea-
sures (van den Berg et al., 2015).
 10 J. Sin and D. Spain
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Figure 3. (a) Forest plot of comparison: individual TFCBT versus usual care on outcome of
PTSD severity – as measured by CAPS (high = poor). (b) Forest plot of comparison: individ-
ual TFCBT versus usual care on outcome of loss of PTSD diagnosis (below diagnostic
threshold as measured by CAPS).

PTSD psychoeducation versus TFCBT

One trial (n = 67) compared TFCBT with PTSD psychoeducation (Mueser et al.,
2015). Analyses of subgroup data did not provide evidence that this brief interven-
tion gleaned greater improvement, compared with TFCBT on CAPS and PTCI.
There were no significant differences between groups in measures of quality of life,
or of psychotic and affective symptoms.

CRI versus usual care

One study evaluated the effectiveness of CRI compared to usual care for reducing
trauma, depression and low self-esteem in young adults following a FEP (n = 66)
 Psychosis 11

(Jackson et al., 2009). Participants who received CRI tended to have lower levels of
post-intervention trauma symptoms, a finding which remained at six-month follow
up, particularly for those individuals who had high pre-treatment levels of trauma.
Depression and self-esteem scores, however, were not significantly improved follow-
ing the active intervention.

Discussion
Individuals who have psychosis often experience trauma and PTSD. This review
summarised the effectiveness of TFPT for this comorbid population. Five studies
met the pre-specified inclusion criteria. Overall, the review findings provide some
good quality, albeit limited, evidence to support the use of TFPT, particularly those
derived from cognitive-behavioural frameworks (TFCBT and CRI) and EMDR:
active interventions were associated with improvement in clinician-rated and self-
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reported trauma symptoms. Benefits of interventions for low mood, anxiety and self-
esteem, were equivocal. These findings are consistent with existing reviews about
TFPT for non-psychosis population (e.g. Bisson et al., 2013; Bradley, Greene, Russ,
Dutra, & Westen, 2005); but additionally, provide preliminary support for interven-
tions designed to address the experience, distress and impact of having psychosis.
Several factors potentially affect the generalisability of study findings. Although
participants were recruited from clinical services, fairly stringent exclusion criteria
were in place, including no recent inpatient admissions, changes to medication
regime, and no coexisting substance dependence. The degree to which these criteria
render a significant proportion of service users ineligible is questionable. All bar one
study (van den Berg et al., 2015) modified standard TFPT protocols so as to accom-
modate psychotic symptoms and associated cognitive processing difficulties (see
Implications for practice, below). Service constraints (for example, resources and
staffing) and clinical complexity, may mean that it is difficult to follow a protocol-
derived treatment in routine care, as well as offering an extended course of sessions.
Furthermore, as study participants also received usual care during the trial, this high-
lights the importance of continuous multidisciplinary team input to address the often
complex clinical needs and presentation.

Limitations
While the search strategy was rigorous, it is possible that studies which included a
small proportion of individuals with psychosis may not have been retrieved, e.g.
because trial authors subsumed psychosis under the umbrella term of SMI. Also,
despite delineating between different intervention modalities and analysing the data
separately, there was some unexplained heterogeneity evident when comparing
TFCBT with usual care. Consequently, the quality of evidence in several analyses
was downgraded.

Practice implications
Although assessment and intervention for psychotic symptoms often takes
precedence, clinicians should be aware of the possibility that service users may have
concurrent PTSD or may previously or currently be experiencing trauma. Hence,
assessment of PTSD symptoms is pragmatic when working with this clinical
 12 J. Sin and D. Spain

population, but decisions about when and how to do so rely on individual need. This
is particularly the case when working with people who have florid symptoms and
high levels of distress. Assessment is likely to be enhanced if there is a strong thera-
peutic relationship between the clinician and service user.
TFCBT and EMDR both appear to have clinical utility, augmented by concurrent
MDT input. Study findings indicate that modifications are needed, in order to
accommodate the unique needs of this group. Service users likely benefit from an
extended course of treatment, with emphasis on engagement and therapeutic trust
and a focus on relapse prevention. The duration of sessions should be based on indi-
vidual need, i.e. depending on whether service users are able to sustain attention for
an hour, or whether shorter sessions are better tolerated. Use of written and visual
materials that are simply laid out, concise and focused may be important for accom-
modating cognitive processing difficulties (Mueser et al., 2008, 2015). To avoid
overwhelming service users and to promote sequential hypothesis testing, it is
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important for clinicians to decide when to target PTSD symptoms, i.e. before or after
other presenting difficulties. In general terms, clinicians should strive to integrate
traumatic experiences and associated distress within the treatment formulation, in
order to inform goals. This is crucial because traumatic experiences are likely to
influence and be influenced by the individual’s symptom presentation, but also as
this may indirectly encourage concern or ambivalence about engaging with clini-
cians (Mueser et al., 2009; Read et al., 2008).

Research implications
Building on the existing studies, we suggest further research endeavours are needed
and could include: RCTs that compare different treatment modalities; consideration
as to the optimal dose, i.e. number of sessions required to maximise treatment gains;
assessment of acceptability and satisfaction with interventions; investigation into fac-
tors that mediate compliance, as well as treatment response (or lack thereof); and
validation of PTSD self-report measures for individuals with psychosis (de Bont
et al., 2015). Future research should also focus on establishing how best to provide
therapists with training, so as to facilitate larger-scale implementation of TFPT.

Conclusion
The findings of this review provide preliminary support for the use of TFPT, specifi-
cally TFCBT and EMDR for adults who have psychosis. Study results are compara-
ble to non-psychosis samples. The clinical implication is clear: assessment and
treatment for PTSD and trauma symptoms are necessary in routine practice. Further
research is needed to establish (1) which intervention modalities glean more favour-
able outcomes; (2) the optimum number of sessions required; and (3) how best to
ensure that interventions are acceptable for service users.

Acknowledgements
The authors acknowledge the expert input provided by the Cochrane Schizophrenia Group
(CSG) Trials Search Coordinator, Farhad Shokraneh who devised and executed the search
strategies for trials in the Cochrane Schizophrenia Group’s Study-Based Register of
Controlled Trials. The current review is derived from a Cochrane systematic review entitled
 Psychosis 13

“Psychological interventions for PTSD in people with severe mental illness”, but has a
broader remit. We thank the co-authors Marie Furuta, Trevor Murrells, Ian Norman and the
CSG editorial team members for their contributions to the Cochrane systematic review. The
views expressed are those of the authors and not necessarily those of the NHS, the NIHR or
the Department of Health.

Disclosure statement
No potential conflict of interest was reported by the authors. JS was involved in the “Cogni-
tive behaviour therapy for post-traumatic stress disorder and schizophrenia
ISRCTN67096137)” (Steel, 2010) in the capacity of a trial therapist from 2009 to 2010.

Funding
JS is funded by a NIHR Post Doctoral Research Fellowship (PDF-2015-08-035, 2016-2020)
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and also supported, in part, by a King’s College London Prize Fellowship (funded by NIHR
BRC based at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London,
2015-2017). DS is funded by a NIHR Clinical Doctoral Research Fellowship (CDRF-2012-
03-059, 2013-2016). This current publication represents independent research not funded by
the National Institute for Health Research (NIHR).

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