Running head: TRAUMA THERAPY IN TREATMENT OF PSYCHOSIS COMPLEX TRAUMA THERAPY IN THE TREATMENT OF PSYCHOSIS: TOWARD AN INTEGRATIVE APPROACH A DISSERTATION SUBMITTED TO THE FACULTY OF THE GRADUATE SCHOOL OF APPLIED AND PROFESSIONAL PSYCHOLOGY OF RUTGERS, THE STATE UNIVERSITY OF NEW JERSEY BY LILLIE I. VANDEKAR IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PSYCHOLOGY NEW BRUNSWICK, NEW JERSEY OCTOBER 2019 APPROVED: ___________________________ Monica J. Indart, Psy.D. ___________________________ Louis A. Sass, Ph.D. DEAN: __________________________ Francine Conway, Ph.D. TRAUMA THERAPY IN TREATMENT OF PSYCHOSIS ii Abstract An increasing number of studies have demonstrated that there is a high incidence of childhood trauma and posttraumatic stress disorder (PTSD) in individuals with schizophrenia, yet established treatments for psychosis do not address trauma. Recently, there has been an increasing emphasis on incorporating trauma treatment into care for schizophrenia. Despite heightened awareness of the need, there is little information available detailing an effective treatment strategy specifically tailored to this population. To address this need, a phase-oriented individual psychotherapy model is proposed that integrates Courtois and Ford’s (2013) relationship based model, widely recognized as the gold-standard treatment for the treatment of complex trauma, with interpersonal psychodynamic treatment for schizophrenia. The theoretical rationale for the choice of models and their integration are provided along with the historical development leading to the creation of each model. The proposed integrated model is designed for an outpatient population of individuals with psychosis and complex PTSD and is broken down into three general phases. Broadly, Phase I addresses safety, stabilization, and engagement, Phase II focuses on psychosis specific and trauma specific processing, and Phase III involves the consolidation of treatment gains and preparation for treatment termination. Following the outline of the model, a theoretical study is proposed to evaluate the effectiveness of this model in a population of individuals with first episode psychosis and complex PTSD, as compared to two control groups. TRAUMA THERAPY IN TREATMENT OF PSYCHOSIS iii ACKNOWLEDGEMENTS I would like to express my deepest gratitude to my dissertation committee, Monica Indart, Psy.D. and Louis Sass, Ph.D. Monica, the difficult trauma work that you do and the impact you have made in others’ lives, inspires me every day. You emanate warmth and support and have been a wonderful mentor throughout my training at GSAPP. Thank you for your belief in me throughout this process. Louis, thank you for perceptively pointing me toward the work of psychologist John Read, whose research spurred the whole idea for this dissertation, and for your invaluable insight, feedback, and support along the way. I feel incredibly lucky to have had you as both an advisor and professor throughout my graduate career. You taught me a new way of looking at and thinking about experience, without which, I would not be who I am today. Thank you as well to my UHCL Counseling Services family. I could not have completed this without your support. Jonathan, thank you for your patience and helping me “make space” for this process while on internship. Jason, thank you for your empathy, holding me accountable, and always encouraging me to find my voice. Russell and Micah, your support, encouragement, and friendship were invaluable. To all of my friends and family- thank you for your patience, support, and understanding throughout this sometimes seemingly unending process. Simon, thank you for being my partner on this journey since our intro-to-psychology days at Penn State. Your love and support helped me keep my sanity through it all. Thank you for listening and for your patience. You have always encouraged me to pursue my goals, inspired me to work hard, and believed in me, and for that I am grateful. TRAUMA THERAPY IN TREATMENT OF PSYCHOSIS iv TABLE OF CONTENTS ABSTRACT .................................................................................................................................... ii ACKNOWLEDGEMENTS ........................................................................................................... iii INTRODUCTION .......................................................................................................................... 1 Purpose and Rationale......................................................................................................... 1 LITERATURE REVIEW ............................................................................................................... 5 Trauma ................................................................................................................................ 5 Complex Trauma ................................................................................................................ 8 Treatment of Complex Trauma ......................................................................................... 10 Goals. .................................................................................................................... 13 Assessment. ........................................................................................................... 15 Phase I. .................................................................................................................. 18 Phase II.................................................................................................................. 19 Phase III. ............................................................................................................... 20 Complex Trauma in Psychosis.......................................................................................... 20 Correlational studies. ............................................................................................ 21 Longitudinal studies. ............................................................................................. 23 Meta-analyses. ...................................................................................................... 24 Psychotherapy for Psychosis............................................................................................. 26 Psychodynamic treatment. .................................................................................... 26 Cognitive Behavioral Therapy for psychosis (CBTp). ......................................... 47 PTSD treatment and psychosis. ............................................................................ 51 Complex Trauma Therapy in the Treatment of Schizophrenia ........................................ 53 TRAUMA THERAPY IN TREATMENT OF PSYCHOSIS v METHODS ................................................................................................................................... 56 Process .............................................................................................................................. 56 The construction of treatment guidelines. ............................................................. 56 Overview of proposed integrated treatment model. .............................................. 58 The Integrated Model ........................................................................................................ 60 Symptomology ...................................................................................................... 61 Treatment preparation. .......................................................................................... 78 Goals. .................................................................................................................... 85 Assessment. ........................................................................................................... 86 Phase I. .................................................................................................................. 92 Phase II.................................................................................................................. 97 Phase III. ............................................................................................................. 107 PROPOSED EVALUATION FRAMEWORK .......................................................................... 113 Participants ...................................................................................................................... 114 Proposed inclusion criteria. ................................................................................. 114 Proposed exclusion criteria. ................................................................................ 116 Outcome .......................................................................................................................... 117 Proposed measures. ............................................................................................. 117 Proposed analysis ................................................................................................ 120 Summary and future directions. ...................................................................................... 121 REFERENCES ........................................................................................................................... 123 TRAUMA THERAPY IN TREATMENT OF PSYCHOSIS 1 Introduction Purpose and Rationale Over the last two decades, evidence has been accumulating showing that schizophrenia is