Rachel Ashwick - Thesis submitted in partial fulfilment of the degree of Doctor of Clinical Psychology (DClinPsych)
Keywords: depression
shame
anger
mental defeat
interpersonal
PTSD
trauma
postnatal
birth trauma
guilt
meta-analysis
perinatal
post-traumatic stress disorder

Critical Review of the Literature
Objectives: To investigate whether trauma-focused therapies for PTSD effectively reduce non-fear emotions of depression, anger, guilt and shame compared to treatment as usual and other therapeutic interventions. Methods: PsycINFO, Medline, Embase, PubMed, Cinahl, Scopus and Google Scholar were searched in April 2022. Included studies were RCT’s, compared a trauma-focused therapy to a control or other therapeutic intervention in a sample of participants meeting criteria for PTSD, reported measures of shame, guilt, anger or depression, and were delivered individually face-to-face. The Cochrane risk of bias tool and GRADE framework were used to assess the quality of included studies and a pre-designed data extraction sheet was used.
Results: 73 studies were identified and a total of 70 RCTs comprising 5,199 participants were included in the meta-analyses; 70 examined depression, nine examined anger, five examined guilt, and three examined shame. Trauma-focused therapies significantly reduced depression compared to treatment as usual (g=-0.96, 95% CI, -1.12 to -0.80) and non-trauma-focused treatments (g=-0.29, 95% CI, -0.50 to -0.08); however, there were no significant differences for anger compared to treatment as usual (g=-0.22, 95% CI, -1.54 to 1.09) or non-trauma-focused treatments (g=0.01, 95% CI, -0.24 to 0.25). Few studies reported outcomes for guilt and shame, with findings showing no significant difference between prolonged exposure and other trauma-focused therapies for guilt (g=0.06, 95% CI, -0.21 to 0.32) and shame (g=-0.09, 95% CI, -0.62 to 0.44).
Discussion: Trauma-focused therapies appear to reduce depression in individuals with PTSD but may not be as effective for anger. The few studies that reported on anger, guilt and shame presented with a high risk of bias in several domains. Therefore, additional research is needed to explore the impact of PTSD treatments on non-fear emotions and help determine which treatments work best for anger, guilt and shame.
Service Improvement Project
This service improvement project explored the information needs of service users (SU’s) within a Birth Trauma Pathway in the Berkshire Traumatic Stress Service and developed a booklet based on recommendations. Routine service outcome and satisfaction data, a self-report questionnaire and semi-structured interviews with eight birth trauma SU’s were used to gather feedback and suggestions for improvements. Overall, findings indicated that SU’s were neither satisfied nor unsatisfied with the current information given. Interviews revealed the need for information on understanding birth trauma, learning about the treatment pathway, normalising birth trauma and overcoming barriers to help-seeking, coping strategies, and the aesthetics and practicalities of delivering the information. Subsequently, an information booklet for the Birth Trauma Pathway was designed in collaboration with four birth trauma SU’s. After an 18-month pilot, pre and post data will later be compared to determine differences in SU satisfaction, drop-out and non-attendance rates after introducing the booklet.
Theoretically Driven Research Project
The aim of this study was to explore the role of current appraisals of mental defeat in interpersonal versus non-interpersonal traumas. A cross-sectional design was employed, where 164 participants, 104 with interpersonal and 60 with non-interpersonal traumas completed measures on type of traumas, PTSD severity and appraisals of mental defeat. The main findings revealed that having experienced interpersonal traumas was associated with significantly higher scores of mental defeat than having experienced non-interpersonal traumas when accounting for sex, number of trauma types and time since trauma. Secondary analyses revealed that interpersonal traumas were associated with more severe PTSD symptoms compared to non-interpersonal traumas via mental defeat as a mediator. Overall, current appraisals of mental defeat appear to play an important role in PTSD, particularly following interpersonal traumas. However, additional research is needed to explore the mechanisms by which cumulative trauma exposure increases PTSD severity.