TOWARD A PSYCHOTHERAPY INTEGRATION APPROACH FOR COMPLEX POST TRAUMATIC STRESS DISORDER: A CRITICAL LITERATURE REVIEW A Doctoral Research Paper Presented to the Faculty of the Rosemead School of Psychology Biola University In Partial Fulfillment of the Requirements for the Degree Doctor of Psychology by Jacob Russell Confer August, 2013 Copyright © 2013 by Jacob Russell Confer ABSTRACT TOWARD A PSYCHOTHERAPY INTEGRATION APPROACH FOR COMPLEX POST TRAUMATIC STRESS DISORDER: A CRITICAL LITERATURE REVIEW by Jacob Russell Confer The symptoms, assessment, and treatments of Post Traumatic Stress Disorder (PTSD) have been empirically investigated to the extent that there is a breadth of valid and reliable instruments investigating this psychopathological syndrome. There, too, exists a substantial evidence base for various treatment models demonstrating effectiveness in treating PTSD. There are, however, no instruments designed to investigate the phenomena associated with Complex PTSD, and it has yet to find its place in the Diagnostic and Statistical Manual for Mental Disorders. There are also few outcome studies demonstrating effectiveness of various treatment approaches for Complex PTSD. Consequently, the current paper is an exhaustive literature review of outcome studies from various theoretical treatment orientations that have demonstrated effectiveness in the treatment of Complex PTSD. The paper closes with a review of various psychotherapy integration approaches and how those may be applied to the current research reviewed. iii TABLE OF CONTENTS PAGE LIST OF TABLES........................................................................................................... viii ACKNOWLEDGEMENTS.............................................................................................. vii DOCTORAL RESEARCH PAPER ................................................................................... 1 Introduction................................................................................................................... 1 Etiology of Complex PTSD.......................................................................................... 2 Definitions of Complex PTSD...................................................................................... 3 Developmental Detriments of Complex PTSD ............................................................ 4 Clinical Presentation of Complex PTSD ...................................................................... 4 Cognitive Symptomology....................................................................................... 6 Affective Symptomology........................................................................................ 7 Interpersonal Symptomology.................................................................................. 8 Intrapersonal Symptomology................................................................................ 10 Somatic Symptomology........................................................................................ 11 Behavioral Symptomology ................................................................................... 11 Summary of Complex PTSD Clinical Presentation.............................................. 12 Research on Complex PTSD ...................................................................................... 13 Methodological and Statistical Considerations........................................................... 14 Lack of Operational Definitions ........................................................................... 15 Efficacy Versus Effectiveness Studies ................................................................. 18 Treating Therapists in the Studies and Related Concerns .................................... 19 iv PAGE Research Designs.................................................................................................. 20 Measurement of Outcomes and Statistical Analyses............................................ 22 Treatment of Complex PTSD ..................................................................................... 27 Cognitive Behavioral Therapy.................................................................................... 28 Cognitive Behavioral Therapy: Exposure Treatment ........................................... 30 Cognitive Behavioral Therapy: Skills Training.................................................... 38 Cognitive Behavioral Therapy: Cognitive Processing and Group Treatment ...... 46 Eye Movement Desensitization and Reprocessing..................................................... 50 EMDR: Quantitative Outcomes............................................................................ 53 EMDR: Qualitative Outcomes.............................................................................. 60 Emotion Focused Therapy .......................................................................................... 65 EFT: Quantitative Outcomes ................................................................................ 67 EFT: Comparison of Two Types of Treatment .................................................... 72 EFT: Qualitative Outcomes .................................................................................. 77 Psychodynamic Psychotherapy................................................................................... 84 Psychodynamic Psychotherapy: Short-Term Treatment Outcomes ..................... 86 Psychodynamic Psychotherapy: Brief Treatment Outcomes................................ 91 Psychodynamic Psychotherapy: Combined Brief and EMDR Outcomes ............ 96 General Treatment Techniques................................................................................. 102 Expert Clinician Survey...................................................................................... 102 Presence of Complex PTSD symptoms........................................................ 105 Contributors to impairment........................................................................... 105 v PAGE Overall approach to treatment....................................................................... 106 Effectiveness of interventions....................................................................... 107 Safety of interventions.................................................................................. 107 Acceptability of interventions....................................................................... 108 Preferred treatment modality ........................................................................ 109 First line interventions for specific symptom sets ........................................ 109 Summary....................................................................................................... 110 Clinician and Patient Survey............................................................................... 111 Benefits of therapy........................................................................................ 113 Challenges of therapy ................................................................................... 115 Recommendations for treatment................................................................... 117 Summary....................................................................................................... 118 Psychotherapy Integration ........................................................................................ 119 Integrative Psychotherapy and Psychotherapy Integration................................. 120 The Prevalence of Psychotherapy Integration .................................................... 121 Types of Psychotherapy Integration ................................................................... 123 Technical/Prescriptive Eclecticism............................................................... 124 Theoretical Integration.................................................................................. 124 Assimilative Integration................................................................................ 125 Common Factors Approach.......................................................................... 125 A Conceptually Based Approach to an Integrative Process ............................... 126 Assessment and case conceptualization........................................................ 127 vi PAGE Implementation of a flexible treatment......................................................... 128 Summary of an Integrative Approach............................................................133 Conclusion ................................................................................................................ 135 REFERENCES ............................................................................................................... 137 VITA................................................................................................................................150 vii LIST OF TABLES Table 1 STAI and QOLI Means....................................................................................35 viii ACKNOWLEDGEMENTS “Don’t let us forget that the causes of human actions are usually immeasurably more complex and varied than our subsequent explanations of them.” − Fyodor Dostoevsky, The Idiot This doctoral paper marks an integration of several years of formal academic training, clinical experience guided by intensive supervision and consultation, and personal and spiritual growth. This project is not merely an intellectual exercise wherein