What Have Been the Experiences of Female Survivors of Interpersonal Trauma on the Survive & Thrive Course
Phase: NA
Conditions: Interpersonal Trauma
Sponsor: NHS Tayside

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Research title: Understanding female survivors of interpersonal trauma experience of 
Survive & Thrive Course 
Chief Investigator: Dr Lucie Bartoskova, Counselling Psychologist 
REC Reference: 18/ES/0113 
End of study report summary date: 14.11.2019 
 
 
Background: Most research has concentrated on individual psychological interventions with 
a limited focus on the effectiveness of manualised group-based approaches for those 
presenting with mental health difficulties following trauma. Survive & Thrive is a 10-week 
psychoeducational course designed for survivors of interpersonal trauma which utilises 
cognitive behavioural skills training while delivering psychoeducation on how a history of 
victimisation can impact on the survivors’ life. However, relatively little research has been 
published on the effectiveness of this course.   
Aims: This study has been designed to gain an insight into female survivors of interpersonal 
trauma experiences of attending the Survive & Thrive course and to evaluate this form of 
psychological intervention.  
Method: To gain an understanding of the female survivors of interpersonal trauma 
experience of the course a qualitative approach has been adopted. Following completion of 
the Survive & Thrive course patients were invited to take part in this study resulting in a total 
of 13 females participating in semi-structured interviews. Access to some demographic 
information of the participants was granted to further inform the qualitative findings regarding 
their experience. The data was analysed in accordance with the Interpretative 
Phenomenological Analysis.  
Findings: Participants’ perceptions about their experience of attending the Survive & Thrive 
course indicated five superordinate themes: ‘sense of connectedness’; ‘journey towards 
recovery’; ‘facing the facts & the past’; ‘initial apprehension’; and ‘sense of being let down’.  
Conclusion: The emerging themes indicate that female survivors of interpersonal trauma 
have benefited from attending the Survive & Thrive course. The participants described this 
as a journey towards recovery. The findings are further discussed in relation to the 
implications for patients and the importance of appropriate use of psychoeducational 
courses, such as Survive & Thrive.  
Keywords: interpersonal trauma, psychoeducation, female survivors, group settings 
 
 

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There is an increasing number of individuals being exposed to traumatic life events who are 
seeking mental health support, which is linked to an increased number of patients being 
referred to Psychological Services (e.g. Alistic et al., 2014; Hopper et al., 2018). Hannah 
Gibbons (2016) reviewed referral rates to Tayside Adult Psychological Therapies Services 
between April and mid-July 2016. Her findings have shown that over half of the patients 
assessed during this time period had a high level of trauma symptoms that impacted on their 
psychological functioning. This means that over half of the patients referred to adult 
psychology in primary care present with some trauma history and would benefit from trauma-
based treatment.  
 
Effect of interpersonal trauma on mental health 
This study concentrates specifically on interpersonal trauma, which is defined as having a 
traumatic experience in relation to emotional, physical, and/or sexual abuse in childhood 
and/or adulthood. Exposure to traumatic events during childhood can substantially influence 
the child’s development which is strongly associated with experiencing mental health issues 
throughout their lifespan (Hetzel-Riggin & Roby, 2013). A recent meta-analysis by Alistic and 
colleagues (2014) showed on average 15.9% of posttraumatic stress disorder prevalence 
across trauma-exposed children and adolescents. Hence surviving interpersonal trauma can 
influence a number of individuals’ functioning abilities, such as their emotional regulation, 
alterations in attention and consciousness (dissociative symptoms), self-perception (self-
blame, guilt), in perception of the perpetrator (acceptance of the perpetrator’s belief system), 
difficulties with both trust and intimacy, impact on their sense of safety (anxiety), and sense 
of hopelessness (depression) (Courtois, 2008).  
 
 
Evidence-based treatment for trauma 
The majority of the research has concentrated on individual psychological treatment 
approaches for patients with historical trauma to address the above associated presenting 
symptoms. Courtois and Ford (2009) argued that at a service level, group therapy is more 
efficient than individual as it can be offered more broadly. This also provides patients with a 
sense of normalisation of their symptoms as a response to trauma and with a sense of not 
being alone; not being the only one who feels this way (Foy et al., 2001; Lukens & 
McFarlane, 2004). Additionally, it counteracts isolation, provides peer support and 
observational learning while ameliorating important shame/guilt-based cognitions (Herman, 
1992, Lukens & McFarlane, 2004). There is however limited research on the effectiveness of 
manualised approaches for the mental health difficulties.  
 
Research shows that safety and stabilisation in trauma survivors can be achieved through 
psychoeducation approaches which emphasise present time, coping strategies/skills, 

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elimination of self-harming behaviour, control over acute symptoms, and increased self-care 
(Lubin et al., 1998; Lukens & McFarlane, 2004). Herman’s (1992) trauma work provides a 
conceptual framework which identifies three phases of trauma recovery starting with (1) 
safety and stabilisation; (2) remembrance and mourning; and (3) reconnection. Thus, 
psychoeducation is crucial in the initial safety and stabilisation stage as it provides patients 
with the chance to make connections between trauma history and current difficulties while 
addressing the origins of current dysfunctional behaviours as attempts to cope with 
overwhelming stress. It then introduces patients to alternative coping strategies.  
 
Additionally, a systemic review and meta-analysis by Mahoney, Karatzias and Hutton (2019) 
offers further support for group-based treatment for adults with symptoms of post-traumatic 
stress disorder. Their study indicated the importance of both trauma memory processing and 
psychoeducational approaches alone treatment forms. Their meta-analysis further suggests 
that early interventions that are offered as part of a phased approach in regard to symptoms 
specific psychoeducational nature are potentially more effective than usual care in improving 
post-traumatic stress symptoms. Thus, the current evidence-based research highlights the 
benefits of a group-based treatment as part of the Phase 1 (safety and stabilisation) 
treatment for trauma prior to patients proceeding towards more individual-based treatment to 
safely process their trauma memories (Phase 2 – remembrance and mourning).  
 
 
Psychoeducational course for survivors of interpersonal trauma 
To-date there have only been two studies that have looked at evaluating the Survive & 
Thrive course (Ferguson, 2008). This is a psychoeducational course that was designed for 
people who have lived through traumatic life experiences such as child abuse or neglect, 
domestic abuse, stalking or harassment. The course aims to help attendees develop an 
understanding of the normal range of reactions to trauma and introduce new ways of coping. 
It is a 10-week course that is structured to utilise cognitive behavioural skills training while 
delivering psychoeducational information on how a history of victimisation negatively impacts 
on the lives of trauma survivors. Each week the course runs for 2 hours and covers different 
topics related to interpersonal trauma such as what is abuse and trauma, what are the 
effects of both, keeping safe, and addressing common mental health difficulties associated 
with interpersonal trauma history. The course is facilitated by two clinicians who have 
qualifications in mental health and have attended the 2 ½ day Survive & Thrive facilitator 
training.  
 
One of the two studies that looked at the Survive & Thrive course effectiveness concentrated 
on female offenders’ experience of the course (Ball et al., 2013). The study results indicated 
statistically significant differences between pre- and post-treatment scores, supporting the 

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effectiveness of psychoeducational group-based treatment for survivors of interpersonal 
trauma. Unfortunately, the purity of reflecting on the effectiveness of this course has been 
impacted on by the researchers modifying the structure of those sessions from 10 weeks to 
8. Additionally, their study cannot be generalised to the wider population, as it focused only 
on female offenders with a history of interpersonal trauma.   
 
The second study (Karatzias et al., 2014) concentrated only on survivors of childhood sexual 
abuse. This was a mixed-method study, the qualitative part of the study was built on a 
quantitative study that showed no clinically significant change over time in participants 
presenting problems. Although the results showed no change over time in general distress 
levels, traumatic symptomatology, depression, anxiety, self-esteem, and life satisfactions, 
participants were less likely to report self-harm and presented with decreased rates of 
smoking, alcohol and substance misuse, as well as involvement in illegal and antisocial 
behaviours at post-treatment and follow-up. The qualitative data also suggested overall 
satisfaction with the course, despite the high attrition rate of 43% and some apprehension 
prior to starting it (Karatzias et al., 2014). The participants further identified increased 
acceptance of the reality of the abuse as a key achievement based on the learning 
experience they have acquired from the course.  
 
The second study findings have however been based on recruiting both female (89.2%) and 
male (10.8%) participants while not elaborating on how the female and male survivors of 
interpersonal trauma experiences may differ. Research has indicated that women report 
more sexual assaults in adulthood associated with elevated baseline guilt conditions and 
health related complaints, whereas men reported more baseline anger directed inward 
(Miller & Cromer, 2015). Therefore, some details have clearly been missed in this mixed 
design study.  
 
 
Research aims 
There is limited research into the manualised group-based therapy approach for trauma. 
This study was designed to address the existing gap in the literature and contribute to the 
understanding of female survivors of interpersonal trauma experience of psychoeducational 
courses (namely the Survive & Thrive). This research’s exploratory structure is inherently 
phenomenologically oriented. By understanding participants’ experience, the course could 
be further tailored to their needs. Hence it can inform professionals how to adapt the more 
challenging parts of the course to ensure that future patients further benefit from the course, 
preventing early disengagement from the treatment.  
 

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Methods 
Participants 
Participants were patients seen within NHS Tayside who have been referred to the Survive 
& Thrive course run within Tayside Adult Psychology Service. Thirteen female patients, who 
met the inclusion criteria, have been interviewed about their experience. See Table 1. for 
additional demographic information regarding each participant.  
 
Inclusion criteria 
Women between the ages of 18 - 65 with a history of interpersonal trauma who attended at 
least 6 out of the 10 sessions of the Survive & Thrive course.  
 
Exclusion criteria 
The main exclusion criteria were that the participants were not perpetrators themselves and 
have not attended a group co-facilitated by the chief investigator.  
 
Procedure 
NHS ethical approval was sought prior to the commencement of the research process. Once 
approval was granted current and past female patients who attended the Survive & Thrive 
course and met the inclusion criteria were informed of this study by the Survive & Thrive 
team or course co-facilitators. When they agreed to be contacted by the chief investigator 
regarding the study, contact was made to provide them with additional information about the 
study. Consent forms were signed to confirm their understanding of the study and agreeing 
to part taking. Each participant then attended an approximately 30 minutes semi-structured 
interview which explored their experience of the Survive & Thrive course, with a particular 
focus on what parts of it they found beneficial and which were more challenging. Each 
interview began with a neutral open-ended question, such as: ‘‘What has been your 
experience of attending the Survive & Thrive course?’’ The conversation developed during 
the course of the interview into unique interactions typical of the verbatim. The transcript 
omitted non-verbal signals however it incorporated pauses, overlapping speech and 
interviewee’s change of intonation. The interview was followed by a 15 minutes off-tape 
discussion regarding their experience of the interview. Each participant was also provided 
with a list of contact numbers if they required additional support.  
Access was also gained to some demographic information that each patient completed 
during the Survive & Thrive course as part of Service evaluation. This information was used 
to further inform the participants’ experience of the course.  
 
 

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Table 1. Participants Demographics 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Design and analysis 
A qualitative approach has been adopted as it looks for socially constructed meanings that 
cannot be assessed by numerical data. Further, it is more sensitive to multiple 
interpretations that individuals may make of their experiences in the process of meaning 
making (Smith, 1996). The data were explored using Interpretative Phenomenological 
Analysis (IPA), a method that has particular resonance for psychologists within qualitative 
research (Smith, 1996). The approach provides participants with space to voice their 
experience, and the meaning they assign to these. IPA is an established, systemic and 
phenomenological-focused approach that allows for the interpretation of first-person 
accounts in a meaning-focused qualitative method (Smith, 1996).  
 
The data analysis involved five separate stages, as part the IPA methodology.  
1. Meaning constructions – transcribed verbatim and was analysed in accordance with 
an idiographic and iterative approach; 
2. Identification of key emerging themes and coding of these – transcript was read 
several times; 
3. Coded themes comprised of constituent themes were clustered into superordinate 
themes – relating those to the overarching dimensions of the interview narratives; 
4. Data was interrogated nomothetically; and 
5. The identified themes within each transcript were inputted into a table of exemplary 
quotes, constituent themes, and superordinate themes (Smith, 1996).  
 
 
Findings 
As outlined in the introduction, previous literature focused on the individual psychological 
treatment option omitting the importance of group-based interventions. During the interviews 
many patients indicated to have been struggling prior to accessing the Survive & Thrive 
course. The demographics table above has also summarised the number of interviewees’ 
attempts on their life, highlighting what some of them reported during the interviews, such as 
a sense of helplessness regarding their future. The main theme that came up was believing 
themselves to be the only one’s feeling this way. Five superordinate themes emerged 
through the analytical process. The interviews offered rich and varied individual expressions 
of these themes, and consistent commonalities allowed some insight into the effectiveness 
of the manualised group-based psychological intervention. It highlighted the meaning 
patients have taken from this experience and the process by which this may occur. See 
Table 2 for a summary of the superordinate and subordinate themes along with example 
quotations from the interviews.   
 
 

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Table 2. Master table of super-ordinate and sub-ordinate themes: example quotations. 
 
 

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Further elaboration of the themes, accompanied by verbatim illustrative data excerpts, is 
provided below.  
 
Theme 1: Sense of connectedness 
This superordinate theme developed as the participants reflected on their experience of self 
while attending the Survive & Thrive course and three subordinate themes emerged that 
contributed to understanding this experience. Diagram 1 shows the chief investigator’s 
interpretation of how the superordinate and respective subordinate themes occurred during 
the interviews. Despite each interview being very individualistic, a pattern has been identified 
in how the participants understood their experience of the Survive & Thrive course and the 
overlaps of the stages which they went through.  
 
1.1. I am not alone 
As a consequence of what victims of an interpersonal trauma experience, they can feel 
alone. Often, they can internalise what has happened to them as being their fault, engaging 
in self-blame. Thus, as highlighted in a number of quote examples below, the most valuable 
aspect of the Survive & Thrive course was the sense of connectedness and not being alone, 
which was also highlighted by some prior literature (e.g. Foy et al., 2001; Lukens & 
McFarlane, 2004). 
 
‘‘...you realise that people are in the same boat as you and before that I’ve 
never thought of that.’’ (Participant5) 
 
Or: 
‘‘...there was people my age and there was also people who were older and 
retired. And I was just like this is really interesting like it’s all ages not just 
like young people and it made you realise that this happens to a lot of 
people and it was quite helpful to know that there was other people going 
through what you I’ve experienced..’’ (Participant11) 
 
And: 
‘‘I’m sitting here crying cos I am really relieved that I got somewhere and 
someone I fitted in. I actually it was like all my life I felt different and didn’t 
feel emotional look at people and think, you know. And I used to think 
different and react differently and think differently, no one really got a sense 
of me....’’ (Participant8) 
  
As well as: 
‘‘I found the experience more ehm beneficial being with others and I was 
quite surprised about that about being in a group, I thought I would be quiet  

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Diagram 1. Representation of superordinate and subordinate themes as they occurred 
during the interviews.  

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but I felt I was wanting to be more supportive towards the other people in 
the group...’’ (Participant9) 
 
1.2 Shared understanding 
The participants then mainly spoke of benefiting from the shared understanding and being 
understood without needing to go into detail about what they have went through.  
For example: 
‘‘It was like the other girls were talking for me... & ...So eh I lot of identify 
identity with other people that I’d never had, I never had, I never had the 
feeling that someone really understood because I didn’t even understand 
myself....’’ (Participant8) 
 
Or: 
‘‘...even though speaking to other people about it, I wasn’t amongst people 
that had also been through it and I think just having that connection of you 
know, not knowing what the specifics were, but having the connection of , 
you know nobody really deserves to be in an abusive situation and you 
know sort of you are strong enough to get through it....’’ (Participant9) 
 
And: 
‘‘Ehm there’s something different about the course to just one-on-one 
therapy, you do your own therapy and you go and you learn more among 
other people who have been through similar experiences to you or at least 
they just understand what it’s like to have had a difficult past.’’ 
(Participant12) 
 
1.3 Safe environment/space 
Given the history of interpersonal trauma, going to new places and building up trust can be 
challenging (e.g. Foy et al., 2001). Therefore, creating a safe environment where the 
patients felt safe to talk amongst each other was important to them, such as:  
‘‘It felt very safe because I knew that the other women that were there, 
were there for the same reasons as me. And it has given me a bit more 
confidence to speak up in a group because we were there all for the same 
reason.’’ (Participant2) 
 
And: 
‘‘Just how it made you feel. It was just really nice and it was a relaxing 
environment as well. And it was safe. No judgement or you know it wasn’t 

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too personal either because it was a group thing. It was good. Really 
good.’’ (Participant6) 
  
Theme 2: Journey towards recovery  
The participants captured their experience of the Survive & Thrive as a ‘journey towards 
recovery’ with the subsequent themes.  
 
2.1. It gets harder before it gets better 
As expected for any psychological treatment, in order to overcome mental health difficulties 
it means having to open up about difficult life experiences or engage in behavioural change. 
This often gets more challenging before patients can start noticing a change (e.g. Beck, 
1997; Tasca et al., 2017). Similar experience has been captured by the participants, such 
as:  
‘‘I think the first couple of weeks were the easy weeks. And then it sort of 
got harder the more in depth it tended to go. And I found it harder the sort 
of last the last three sessions were really tuff. But they were also helpful as 
well.’’ (Participant4) 
 
Or 
‘‘It’s therapy, isn’t it. So it brings out the bad. Because you have to bring it 
all up to understand it now as an adult because everything I have seen as a 
child made no sense to me.’’ (Participant6) 
 
And 
‘‘There was things that was really hard to cope, plus it’s brining up stuff you 
don’t really want to think about, like I know that I was going there to think 
about it, to get used to it, to get over it sort of thing. But it was still really, 
really hard to go cos every time I went I was like I was really reliving it, 
sounds so sad. (laughs).’’ (Participant11) 
 
2.2 Life changing experiences 
Once participants went through the difficult part of the course and started to move towards 
noticing the change, they described this as ‘life changing’. By gaining a better understanding 
of the normal range of emotional response to what they have been through, it has allowed 
them to move away from self-blame while understanding their emotions better. For example:  
‘‘That it made me understand that. That it is not a flaw in me, it is because 
of the lack of learning and caring as a child... But I went through most of my 
adulthood not understanding that and being very ehm scared of people and 
not wanting to take part in things. And being very sensitive and being upset 

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very easily. And I did not know all of these things until I have went along to 
the Survive & Thrive’’ (Participant2) 
 
And 
‘‘It just gave me a new perspective. Like another way to think about things 
rather than the way I was thinking about things. Because I was in like quite 
a bad way. Yeah but I found it amazing, life changing.’’ (Participant6) 
 
Or 
‘‘I’m still here because of that course, I was very bad very depressed very 
suicidal...’’ (Participant7) 
 
2.3 Sense of empowerment 
By understanding what they have been through, learning from each other and not being 
alone in this process, participants reported having a sense of empowerment, such as:  
‘‘But when you realise there were good people and you were kind of willing 
to open up in the group and stuff. So that kind of helped a bit, with well it 
helped me with getting out and being with people again. Because usually I 
just have locked myself away after what had happen.’’ (Participant3) 
 
Or 
‘‘Profoundly it enabled me to help myself that’s what it enabled me to do. 
To identify and help myself I haven’t come out as Wonder Woman, I’m not 
saying that cos you know life aint easy, you know. Ehm but a greater 
insight into the way I think...’’ (Participant8) 
 
And 
‘‘It’s like the, the group gives you this extra bit of strength and courage just 
the way it’s set up and the way they teach and the way that they do things, 
it just it works really well.’’ (Participant12) 
 
2.4 Long way to go 
Most participants reported noticing the benefit of the Survive & Thrive not until couple of 
months after the course came to an end. This has been highlighted in previous literature 
regarding the need for time to consolidate newly acquired skills while having a chance to put 
these into practice (e.g. Pacual et al., 2015). Some have also spoken of the importance of 
handouts they have been given and being able to go back to them. For example:  
‘‘Probably it wouldn’t be until couple of months after it. And then I started 
going back over the sheets and stuff. And because it wasn’t as intense and 

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you weren’t in a room with strangers. I was going through things and 
understand it sort of better and how to apply it and use it.’’ (Participant4) 
 
Recognising the newly acquired skills set that not everyone has: 
‘‘Even though you maybe not thinking it is helping as much at the time, it is when you 
actually reflect back on it when you think, well look these are skills I can take away 
with me. They are not something everybody knows, and that’s for one.’’ (Participant1) 
 
Acknowledging the course is not a ‘cure’ it is a guide to making improvement in one’s quality 
of life (e.g. Tasca et al., 2017): 
‘‘Like even now, there’s things I know I don’t understand everything, I get 
things wrong. I am human. Yeah. It is an ongoing thing. It’s life. You’re 
continuingly learning, you’re continuingly discovering.’’ (Participant6) 
 
Or 
‘‘Now Survive & Thrive it’s not a curing thing, it’s not a click fingers and 
done, but it gives you tools, it gives you the tools to kinda face life and to 
just keep going, which I needed at that time.’’ (Participant7) 
 
Theme 3: Facing the facts & the past  
The participants described the hardest part of the course being facing the facts and having 
the co-facilitators describe what abuse is and the effects of it on one’s mental health. Most of 
the participants have also been recognising the benefits of having to sit through more 
challenging discussions during the course, as it allowed them to gain a better understanding 
of their current mental health (e.g. Hundt et al., 2017; Tasca et al., 2017). The themes below 
captured the process of what the participants explained as having experienced.  
 
3.1. Facing denial & triggers  
This theme that arose from the interviews is a common reflection of psychological treatment 
that has been captured by prior publications (e.g. Hundt et al., 2017; Tasca et al., 2017). 
Patients tend to avoid remembering the past as they are unsure how to process the 
associated emotions with these memories. Thus, many participants described this part of the 
course as triggering and emotionally challenging, such as:  
‘‘The issue with it is that it’s so every single time you go it’s that whole 
session and you are bombarded with all of this. In a positive, not 
bombarded in a negative way. But you think about it and you think about it 
some more and you go over, over, and over it again. So that honestly I 
would seem both as a positive and negative because I take it for me 

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personally if I am thinking about it all the time and working through every 
little bit it holds you in the past..’’ (Participant1) 
 
Or 
‘‘A lot of it, some of it triggered things that I was feeling inside and some of 
the stories were. When the group started sharing stuff, sometimes I would 
leave and be going home and I’ve been physically exhausted. It was like I 
have been in a boxing match.’’ (Participant3) 
 
3.2 Eye opening moments 
A majority of the participants have spoken of the ‘wow’ effect, when they came to a self-
realisation. They have realised that topics they did not identify with initially have actually 
been relevant to them. The main topic from the course that participants described as a big 
eye opener was not realising that repressing anger contributes to some of their unhealthy 
coping strategies, such as:  
‘‘There were certain ones beforehand that I though I won’t be able to 
identify with that because for example the week on anger. That won’t be 
really me. But as has went on, ehm they discussed too much anger and 
also too little anger so it was a really really interesting one because you feel 
you can identify with every part of it in a certain way...’’ (Participant1) 
 
Or 
‘‘Just because I feel guilty about something does not mean that I’ve cause 
it. And being able to share my guilt and the shame you have about the 
abuse has been massive. And that itself has helped you so much. It’s like 
nobody has ever said to me, it is not your guilt. The guilt belongs to the 
abuser. They were the one who were guilty. But they have left you carrying 
their guilt. Nobody has ever said that to me and it was like, WOW.’’ 
(Participant2) 
 
3.3 Acceptance and greater understanding 
The participants expressed how the course allowed them to put the group process into 
perspective (e.g. Hogan et al., 2006). They spoke of the different levels of processing the 
information; being this written or verbal which enabled them to synthesise and consolidate 
their past experience and newly acquired knowledge to understand better their current 
mental health struggles; such as:  
‘‘I started to gain more understanding and awareness into what I feel and 
why I feel the way I do. Just the way they teach, they just give you an 

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insight into why you are going through what you are going through and they 
make sure you don’t feel like you are alone.’’ (Participant12) 
 
Or 
‘‘I found it quite good cos there was like different like methods of like talking 
like they read from the PowerPoint but they also like did things on a flip-
chart as well like that was really good and like it was quite interactive, they 
were like we will all write something down on a post it note and they could.’’ 
(Participant11) 
 
And 
‘‘...but now through the group I can sort of say – oh well I do understand 
now why my body reacts this way and it’s just a panic attack or it’s just a 
low mood and it’s gonna pass.’’ (Participant4) 
 
Theme 4: Initial apprehension 
There has been some initial apprehension from some of the participants prior to starting the 
course. Some spoke of having no hope that anything could help them along with the fear of 
the unknown.  
 
4.1 Sense of helplessness 
Participants described having a sense of helplessness prior to starting the Survive & Thrive 
course. They spoke of the struggle of not receiving the right help and feeling stuck in life.  
‘‘My emotional state and my mental state was quite bad at that time. I was 
working. I was just kind of surviving.’’ (Participant6) 
 
Or 
‘‘Before I took part in the course, I was quite frustrated because I had been 
working quite hard to make a difference in my life and I needed that extra 
help.’’ (Participant12) 
 
4.2 Readiness to change 
Some of the participants captured the importance of when the course was offered to them. 
Given the above explained emotional state and sense of helplessness, they have spoken of 
needing to be in the right place in life when they were ready to make changes and engage 
with the treatment (e.g. Cook et al., 2017; McMurran, 2012). For example:  
‘‘I was really in the right place at the right time wanting it, you know...’’ 
(Participant8) 
 
 

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Or 
‘‘I mean you have to change, you have to be willing to change I think so.’’ 
(Participant12) 
 
4.3 Fear of the unknown 
Many patients fear attending a group-based treatment because of the unknown factor of who 
is going to be in the group. From what the participants described the extra step taken by the 
course co-facilitators who have met with them before hand and showed them the room 
where the course is run made a significant difference for them with regards to them 
attending the initial session; such as:  
‘‘Ehm not knowing what to expect. I did meet CLINICIAN once before so I 
knew I would one person I would recognise her face. Because the thought 
of a group of people that I do not know, group of strangers, very scary.’’ 
(Participant2) 
 
Or 
‘‘I was like really scared because I didn’t know what to expect. And I just 
didn’t know what the other people are going to be like or joining the group. 
And there was a lot of anxiety and stuff. But the staff really helped like 
showing me the room that it’s gonna be in and that.’’ (Participant4) 
 
Theme 5: Sense of being let down 
Despite the above captured positives, the participants have found some challenges with the 
course too. Most of these challenges are areas that are difficult to control for and some 
provided insightful points to take forward in terms of delivering this course regarding the best 
way to support the patients. 
 
5.1. Challenging personalities 
One of the main difficulties among a group-based treatment is the mixture of personalities. 
As captured by the participants despite the co-facilitators’ best efforts, there have been some 
individuals who did not respect some of the course boundaries. Despite the benefits of 
having a group of individuals who share similar experience, as captured above offering the 
‘sense of connectedness’, some patients used the group to over share their personal 
experience of the trauma which others have found triggering. For example:  
‘‘It was actually the individuals. It was jus that some of the trauma that they 
have experienced had triggered some of the stuff in me. And that was quite 
hard to deal with.’’ (Participant3) 
 
Or 

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‘‘...there were few annoyances but that was more to do with group 
members and that. But that’s going to happen whenever you put a group 
together and teach them a lesson, it’s personalities clash.’’ (Participant7) 
 
5.2 Repetitiveness of questionnaires 
The participants struggled with the number of questionnaires they had to complete each 
week as part of the service evaluation. Not only did they find the process of this ‘repetitive’ 
and ‘boring’, but for some it was highlighting the lack of progress they have been making on 
a weekly basis, which has been triggering some participants’ low self-worth.  
‘‘One thing that I found a bit boring but I know that they had to do it was the 
questionnaires. Sometimes because I felt, I felt for a long time the same.’’ 
(Participant5) 
 
Or 
‘‘...it tends to be just adminy stuff to start with I kinda found that quite boring 
and quite annoying... the introductions make me want to push it way, so I 
found those a bit difficult... ’’ (Participant7) 
 
5.3 Need for additional support 
The general feedback was that participants enjoyed the course so much that they did not 
want it to end. Given it allowed them to increase their social levels and sense of 
connectedness this was the most difficult part for them. Some spoke of the loss of contact, 
as they would not get to see each other again: 
‘‘I think when we were kind of put in the group for the 10 sessions and then 
we were kind of given coping skill and stuff and then we have opened up 
about stuff that has happened to us and then all of the sudden it just ended. 
And we have no where to turn to and. A lot of the, the couple of the women 
were like this is it then, we are not going to see each other again. ’’ 
(Participant3) 
 
Some participants stated despite having the co-facilitators available during the break and 
after the course, they would have liked to receive additional support in between 
appointments. This might be linked to the range of individuals attending the course with 
different needs and from different services (e.g. Primary Care Psychology versus 
Community Mental Health Team settings), where different levels of support are provided. For 
example:  
‘‘...if I found the session quite hard. I’d like to speak to someone in a like an 
appointment just to talk about it one on one, something like that....’’ 
(Participant11) 

20 
 
 
One of the disadvantages of a psychoeducational course is the lack of 
opportunity to go over sessions patients did not attend. There are two follow up 
sessions that allow for some summary, but this would not cover in full the session 
someone has missed, such as:  
‘‘...since people are also missing some it would be good to have a kind of 
revision also in the middle maybe or towards you know the end...’’ 
(Participant13) 
     
 
Discussion 
These findings demonstrate that the Survive & Thrive course is not a ‘cure’ for patients with 
a history of interpersonal trauma, however it provides them with new strategies and skills to 
move forward in their life. One of the key themes identified by the participants was the 
‘sense of connectedness’. A sense of belonging and not being alone was described by the 
participants as the main factor contributing to benefiting from completing the Survive & 
Thrive course. Given the tendency for isolation, vulnerability and difficulties around trust that 
survivors of interpersonal trauma experience, being in an environment where their social 
connectedness levels were addressed has helped to improve their overall well-being (e.g. 
Foy et al., 2011; Lukens & McFarlane, 2004). Additionally, having one’s feelings validated by 
others is important to all individuals, however this is particularly important for survivors of 
interpersonal trauma, who’s emotions have often been invalidated and neglected 
contributing to their fear of expressing their feelings (Courtois & Ford, 2009).  
 
The Survive & Thrive course facilitated the participants ability to create connections with 
other group members, thereby helping them to combat isolation and alienation. Participants 
described how sharing their experiences helped to normalise their reactions, which also 
contributed to shame reduction. Similar findings have been captured by other studies mainly 
relating to survivors of complex trauma (e.g. Hopper et al., 2018). The participants also 
described having a ‘sense of empowerment’ as a result of the course, which helped with 
their confidence and increase in social levels by starting to establish healthy boundaries in 
their relationships. Thus, based on these findings, the aim of future studies should be on 
how to increase the uptake of patient’s engagement in inclusive stabilisation groups, while 
exploring how to reduce the burden of participation along with the ‘fear of the unknown’. 
Further research in this area is important not only due to this study’s findings but also other 
literature identifying social support (sense of connectedness) as a mediating factor between 
suicidal ideation and history of neglect in survivors of childhood trauma (e.g. Yong-Chun et 
al., 2017).  
 

21 
 
The additional superordinate and subordinate themes that occurred as a result of the 
interviews are in accordance with general knowledge about the vulnerability, ambivalence, 
and trauma-based treatment approach, which are characteristic of the initial phases of any 
group-based treatment (Yalom & Leszcz, 2005). The study has also offered some insight to 
participants’ experience of the course; in particular Diagram 1 has highlighted the sequences 
of the participants’ experience of the captured themes and the times when additional support 
might have been required. Although boundaries have been set to avoid sharing specific 
trauma experiences, the participants were reminded of specifics through example scenarios 
or by some patients over sharing details regarding their trauma experience. An important 
clinical implication is that course co-facilitators need to focus on patients’ readiness to 
engage with more triggering aspects of the course while providing additional support to help 
those who might also be experiencing additional difficulties, such as co-morbid social 
phobia. As highlighted by the quotes, this requirement could be met by being shown the 
clinical room as well as getting to meet one of the co-facilitators prior to commencing the 
course. Those who find the material triggering could be offered one-to-one review 
appointments on an individual basis at set stages of the course.  
 
Furthermore, the study has highlighted the importance of time to understand the traumatic 
experience as well as to practice the newly acquired skills throughout the course. This was 
captured by the participants as a ‘journey towards recovery’ with the subordinate theme of 
‘long way to go’. Despite its inherent stressors, as would be expected of any trauma-based 
psychological treatment, all the participants spent most of the interviews drawing on the 
positive aspects of attending the Survive & Thrive course. The way participants described 
how the course has helped them was mainly in line with acceptance and understanding the 
distressing emotions while acknowledging that these will pass. It has not made these 
difficulties completely resolved. Additionally, most of the participants spoke of the need for 
consolidation time which enabled participants to put the newly acquired techniques into 
practice while having additional time for self-reflection (e.g. Pascual et al., 2015). Those who 
were interviewed one or two years after completing the Survive & Thrive course reported 
more changes in comparison to those who completed the course between 2-4 months prior 
to the interview. A longitudinal study would be required in order to capture the exact time-line 
of patients progress throughout and after completion of the psychoeducational course.  
 
Overall, this study offers a rich insight into the female survivors of interpersonal trauma 
experience, adding to the previous two studies that focused namely on the effectiveness of 
the Survive & Thrive course. Increasing the insight of the participants’ experience of the 
course might assist clinicians and mental health services in adapting this course to their 
patient population needs and encourage wider use of this manualised psychoeducational 

22 
 
course. Findings from this qualitative study should be encouraging for services in regard to 
recognising the identified benefits participants experienced as a result of completing the 
Survive & Thrive course.  
 
 
Clinical implications 
Given the above captured benefits a group-based manualised psychoeducational course 
can have for female survivors of interpersonal trauma, some of the barriers to engagement 
with this treatment option should be further explored. The findings from the current study 
suggest that receiving additional support both before and throughout the course has been 
vital. Thus, the clinicians who screen suitable patients for this treatment should ensure that 
they explore potential barriers to attending the course and arrange a viewing of the clinic 
room in advance or a meeting with a course co-facilitator.  
 
Given the lack of control over the range of personalities within a group, one of the aspects 
that mental health services might require to focus more on is exploring screening measures 
for readiness to engage with such a treatment option. Despite this study not capturing the 
reasons for disengagement from treatment, some of the participants feedback was around 
readiness and willingness to change. Cook and colleagues (2017) identified patient’s 
readiness to consist of three components: psychological and psychiatric stability, general 
readiness to change, and specific skills to manage trauma-focused evidence-based 
treatments (e.g. distress tolerance, affect regulation skills). Their study highlighted some of 
the current difficulties in the screening process for predicting who is actually ready to 
engage. It has emphasised along with other literature that there is not a specific scale that 
allows mental health services to define ‘‘readiness’’ and this mainly depends on clinicians’ 
individual judgement (e.g. Couineau & Forbes, 2011; Zubkoff et al., 2015). Thus, this area 
might require more exploration in order to identify a uniform measure that can be adapted by 
clinicians across different services.  
 
 
Strengths, limitations, and future directions 
Given the number of patients with a history of interpersonal trauma being seen within 
Psychology Services (e.g. Gibbons, 2016) with new initiatives promoting mental health well-
being, there has been an increased focus on the evaluation of different types of trauma-
based psychological interventions. This study therefore offers a rich insight into female 
survivors of interpersonal trauma experience of the Survive & Thrive course, and the factors 
moderating this experience.  
 

23 
 
The primary limitation of this study is its restricted access to Tayside area population only. 
Thus, to assess effectiveness of this course more broadly and to generalise the findings, this 
study needs to be replicated throughout Scotland to assess for other factors, such as 
deprivation index and/or access to other means of support. Additionally, the participants 
interviewed for this research ranged in terms of time since completion of the course from 
only a few weeks up to two years. To allow for a greater insight into the changes captured 
overtime, future studies could only interview participants a set number of months post 
completion of the course. The highlighted quotes from the interviews have already shown 
some differences among the participants who might have completed the course two years 
ago in comparison to those who completed a month ago. Thus, all of these are additional 
variables of how much time after the course individuals had to consolidate their newly 
acquired skills/learning.  
 
Furthermore, a chief investigator (first author of the study) conducted this study and carried 
out the data analysis, meaning that potential limitations arise in using IPA. This approach 
draws on the researcher interpreting their understanding of the interviews with prior 
knowledge of the researched topic (Smith, 1996). Moustakas (1994) suggested a technique 
called ‘bracketing’ allowing the researcher to set aside their experiences and take a fresh 
perspective. It should however be noted that it is impossible to bracket one’s biases 
completely (e.g. Allen-Collinson, 2009).  
 
 
Conclusion 
The findings of this study highlight that a manualised group-based intervention can be 
equally as effective as some individual psychological interventions, based on the participants 
comments. The study has demonstrated that survivors of interpersonal trauma have 
benefited from being able to identify that they are not the only ones feeling that way and 
having the opportunity to learn from each other, which would not be facilitated through 
individual psychotherapeutic treatment. Thus the ‘sense of connectedness’ should be further 
researched as a potential contributing factor to greater outcome from psychological 
interventions. This research invites mental health professionals and services to evaluate the 
prevalence of individual psychological treatment that is being offered to patients with history 
of interpersonal trauma over group-based psychoeducational treatment, such as the Survive 
& Thrive course.  
 
 
 

24 
 
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