CE Information for Participants Please see front matter for Continuing Education Credit Details and Requirements. Effectiveness and Acceptability of Group Psychoeducation for the Management of Mental Health Problems in Survivors of Child Sex Abuse (CSA), by Thanos Karatzias, Ph.D., Sandra Ferguson, DClinPsych, Zoë Chouliara, Ph.D., Angela Gullone, BSc, Katie Cosgrove, IGDip, and Anne Douglas, Ph.D. Estimated Time to Complete this Activity: 90 minutes Learning Objectives:  The reader will be able to: 1. Describe the evidence base regarding psychoeducational approaches for adult survivors of sexual abuse. 2. Appraise the strengths and weaknesses of a new psychoeducational intervention for adult survivors of sexual abuse. 3. Distinguish between various methodological approaches to evaluate the effectiveness of psychological interventions. Author Disclosures: Thanos Karatzias, Nothing to Disclose Sandra Ferguson, Nothing to Disclose Zoë Chouliara, Nothing to Disclose Angela Gullone, Nothing to Disclose Katie Cosgrove, Nothing to Disclose Anne Douglas, Nothing to Disclose

INTERNATIONAL JOURNAL OF GROUP PSYCHOTHERAPY, 64 (4) 2014 KARATZIAS ET AL. GROUP PSYCHOEDUCATION FOR SURVIVORS OF CHILD SEX ABUSE

Effectiveness and Acceptability of Group Psychoeducation for the Management of Mental Health Problems in Survivors of Child Sexual Abuse (CSA) THANOS KARATZIAS, PH.D. SANDRA FERGUSON, DCLIN PSYCH ZOË CHOULIARA, PH.D. ANGELA GULLONE, BSc KATIE COSGROVE, IGDip ANNE DOUGLAS, PH.D.

ABSTRACT There has been limited published research on the effectiveness of manualized psychoeducational approaches for the mental health and behavioral problems of child sexual abuse (CSA) survivors. The present study aims to add to the evidence base for the effectiveness and acceptability of such interventions. A total of 37 enrolled into a brief psychoeducation program (i.e., 10 sessions) aiming to help stabilize mental health and behavioral outcomes (e.g., self-harm), while on the waiting list for mental health services. Participants completed a set of self-rated measures at baseline, pre-intervention, post-intervention and Thanos Karatzias is affiliated with the Edinburgh Napier University Faculty of Health, Life and Social Sciences in Edinburgh, UK, and with NHS Lothian, Rivers Centre for Traumatic Stress, in Edinburgh. Sandra Ferguson is also affiliated with NHS Lothian, Rivers Centre for Traumatic Stress, in Edinburgh. Zoë Chouliara and Angela Gullone are affiliated with the Edinburgh Napier University Faculty of Health, Life and Social Sciences in Edinburgh. Katie Cosgrove is with the Scottish Government Gender Based Violence Initiative in Edinburgh. Anne Douglas is with the NHS Greater Glasgow and Clyde Trauma Service, in Glasgow, UK.

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3-month follow-up. Although there was no change over time with regard to general distress, traumatic symptomatology, depression, anxiety, self-esteem, and life satisfaction, completers were less likely to report self-harm and presented with decreased rates of smoking, alcohol and substance misuse, and involvement in illegal and antisocial behaviors at post-treatment and follow-up. Qualitative data also suggested that overall the program is well tolerated by participants, despite the high attrition rate (43%). Although further research is required to establish the efficacy of this intervention, preliminary results indicate that the new intervention may be useful for stabilizing behavioral problems at posttreatment and follow-up. Strategies to improve attrition rates in future research and clinical practice are discussed.

I

n a recent review of the literature, Pereda, Guilera, Forns, and Gómez-Benito (2009) reviewed 39 international epidemiological studies in 21 countries on the prevalence of childhood sexual abuse (CSA), using a broad definition of the phenomenon (n = 65–9,953, mean n = 1,647). They reported that the prevalence for males is 0.6–60% and for females 0.5–53.2% across studies. There is evidence to suggest that those who report CSA are also at high risk for a wide range of medical, psychological, and behavioral problems. In a systematic review of 14 reviews aiming to synthesise the evidence of the impact of sexual abuse, Maniglio (2009) found a range of psychological problems to be associated with CSA, including affective, anxiety, eating, personality, sexual, psychotic, dissociative, and somatoform disorders, behavioral problems, including self injurious behavior, self-mutilation, early involvement in sexual activity or prostitution, sexual perpetration, alcohol problems, later revictimization, and social impairment and emotional difficulties, such as high levels of hostility, anger, interpersonal sensitivity, and self-esteem impairment. Relationships were found of small to medium magnitude and moderated by sample source and size. The author concluded that CSA should be considered as “a general, nonspecific risk factor for psychopathology.” Considering the above, a number of CSA survivors will require treatment and support to cope with the mental health consequences of childhood trauma. Evidence suggests that there are certain characteristics of services that survivors value, including a trusting therapeutic relationship, a safe environment to disclose



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abuse, breaking isolation and enhancing self-esteem, and moving towards recovery (Chouliara et al., 2011). Nevertheless, working with CSA survivors can be challenging and lead to vicarious traumatization (Chouliara, Hutchison, & Karatzias, 2009). Therefore, developing appropriate interventions and models of care for CSA survivors is of paramount importance. Although no agreement exists as to what is the best treatment option for the mental health problems of CSA survivors, experts in the area suggest that a staged approach to treatment (Herman, 1992; van der Kolk et al., 1996) can facilitate recovery. Herman (1992) proposed a three-stage model of recovery from traumatic events that focuses on intra- and interpersonal trauma sequelae (i.e., helplessness, lack of safety, emotional and interpersonal disconnection, destruction of meaning systems). The stages are establishing safety, reconstructing the traumatic story, and restoring the connection between survivors and their community. Survivors can move into these three steps dynamically rather than sequentially. Zlotnick and colleagues (1997) have suggested that safety and stabilization in stage 1 could be achieved through psychoeducational approaches which emphasize present-time orientation and short-term goals, such as affect management and coping skills, abstinence from substances, elimination of self-harm behaviors, control over acute symptoms, and increased self-care. Thus, psychoeducational approaches are currently considered by many the intervention of choice for survivors of complex trauma in the early stage of therapeutic contact (Herman, 1992; Cloitre, Koenen, Cohen, & Hans, 2002; Courtois, 2004). PREVIOUS RESEARCH ON THE EFFECTIVENESS OF PSYCHOEDUCATION

Our review of the literature has identified a total of nine studies on the effectiveness of group psychoeducational approaches for CSA survivors within a staged approach to treatment. Of those, a total of three studies employed single group designs (Dorrepaal et al., 2010; Sultan & Long, 1988; Wright, Woo, Muller, Fernandes, & Kraftcheck, 2003). Two were controlled investigations with no random allocation (Stalker & Fry, 1999; Zlotnick et al., 1997), and four were randomized controlled trials with random allocation

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(Morgan & Cummings, 1999; Stalker, Palmer, Wright, & Gebotys, 2005; Talbot et al., 1999; Wallis, 2002). A variety of theoretical models were used across studies ranging from cognitive behavioral (e.g., Dorrepaal et al., 2010) to feminist approaches (e.g., Stalker & Fry, 1999). Most programs aimed to treat traumatic symptomatology (e.g., Stalker et al., 2005) or general stabilization based on Herman’s model (e.g., Talbot et al., 1999). Duration of interventions ranged from intensive six-week inpatient input (e.g., Stalker et al., 2005) to 20 weekly session programs (e.g., Dorrepaal et al., 2010) across studies. Sample size ranged between n = 22 (Sultan & Long, 1988) to n = 218 (Stalker et al., 2005). Irrespective of the design, results across studies indicated that group interventions are beneficial at post-treatment and follow-up assessments for addressing traumatic symptoms (e.g., Dorrepaal et al., 2010), depression (e.g., Morgan & Cummings, 1999), dissociation (e.g., Zlotnick et al., 1997), and general psychopathology (e.g., Stalker & Fry, 1999). Dropout rates ranged between 4% (Wright et al., 2003) to 34% (Morgan & Cummings, 1999) across studies. A range of CSA definitions were used across studies, and many studies involved a limited number of survivors within their sample (e.g., 54% in Sultan & Long, 1988). Although there has been some evidence on the effectiveness of psychoeducational approaches for the mental health problems of CSA survivors, to our knowledge, the present is the first study that employed a low-intensity manualized psychoeducational intervention aimed at stabilizing mental health and behavioral symptomatology in a sample consisting exclusively of CSA survivors. We have hypothesised that the new group-based psychoeducational intervention would lead to improved outcomes in behavioral measures at post-treatment and follow-up. METHODS Aims

This mixed-methods study aimed to provide preliminary evidence on the effectiveness and acceptability of a new brief psychoeducational group intervention for managing mental health and behavioral problems associated with a history of CSA.



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Research Questions

The study attempted to answer the following questions. How effective is group psychoeducation for stabilizing the mental health and behavioral problems of CSA survivors as compared to no input (i.e., waiting list)? Does group psychoeducation produce maintained changes at 3-month follow-up? What are the views and experiences regarding this approach from the patient and professional perspectives? Participants

Participants were a consecutive series of patients (n = 37) from the waiting lists of five National Health Service (NHS) Boards, organized into six women’s groups and one men’s group. Inclusion and exclusion criteria are described as follows. Inclusion Criteria. Patients with a history of CSA related to their current clinical concerns, as described in the referral letter, on the waiting list of participating organizations. CSA was defined as, “the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared, or else that violates the laws and social taboos of society” (World Heatlth Organization, 1999). Patients willing to participate and to give written consent, aged between 18 and 65 years old. Exclusion Criteria. Patients with a diagnosis of severe and enduring conditions including personality, psychotic, and bipolar disorders as described in patients’ files. Patients who attended other formal psychotherapy services in the voluntary or private sector were excluded to control for additional therapy effects. Current substance abuse was not an exclusion criterion, but participants were informed that attendance would be disallowed if they arrived under the influence of alcohol or drugs. Procedure

To control for non-intervention effects, patients stayed on the waiting list of the participating services for eight weeks with no intervention. They were assessed at four time points (enrollment, pre-treatment, post-treatment and three-month follow-up). Quali-

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tative data were also collected after treatment completion. Ethical approval for the study was obtained both from Edinburgh Napier University and the Integrated Research Application System (IRAS). Psychoeducational Intervention: Survive & Thrive

In her groundbreaking work, Herman (1992) described the use of a didactic, present- focused group format to help stabilize clients’ presenting difficulties prior to work with traumatic experience. In line with Herman’s work, the new psychoeducational intervention was designed to help people achieve stabilization in a resource-efficient way while providing support while they were on waiting lists. The focus of the intervention was on safety, stabilization, and affect management skills. A total of 10 manualized group sessions of approximately 1½ hours were offered. Each used an educational format in an informal classroom setting. Groups were run by 14 mental health professionals (2 per group) with a maximum of 12 participants per group. All mental health professionals had a background in clinical psychology, psychotherapy, or counselling and received standardized three-day training on the delivery of the intervention. Regular supervision was also provided during the program. The Survive & Thrive workbook (Ferguson, 2008) was designed to be comprehensive, user-friendly, and culturally sensitive. It is 68 pages long, has nine chapters, and uses a cognitive-behavioral approach. Each chapter represents a session of the course, with an additional (session 1) as a preliminary welcome session that emphasizes safety. Session 2 provides an introduction to abuse and trauma and to the phased intervention approach. Session 3 addresses the physical, emotional, and psychological effects of trauma and abuse. Sessions 4–10 address a range of mental health problems associated with trauma and abuse, including substance abuse, anxiety, and depression. Sessions aim to promote safe coping skills, such as relaxing, learning how to monitor one’s behavior, identifying and challenging negative automatic thoughts, grounding to combat dissociation, and assertiveness skills. Clients are required to perform a number of activities (e.g., lists and reflective diaries) to master these safe coping skills. Completion



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of minor tasks (e.g., increasing activity levels) between sessions is to ensure engagement with the material. MEASURES Quantitative Data

All patients completed the same battery of measures at enrollment, pre-treatment, post-treatment and 3-month follow-up. Quantitative data included a number of self-report measures of demographics and basic outcomes described briefly as follows: Basic demographics included age, gender, and educational attainment. Self-harming was assessed by two questions, “Do you injure yourself in some way?” (Yes/No), and if yes, “Do you usually injure yourself … more than once a week, approximately every two weeks, about once a month, less than once every few months?” Smoking was assessed by two questions, “Do you smoke cigarettes?” and if yes, “How many cigarettes do you smoke per day?” Alcohol consumption was assessed by three questions, “Do you drink alcohol?” (Yes/No), and if yes, “Do you usually drink … more than once a week, approximately every two weeks, about once a month, less than once every few months, and how many units do you usually drink per week?” Similarly, use of illicit substances was assessed by two questions, “Do you use illicit substances” (Yes/No) and if yes, “Do you normally use them … more than once a week, approximately every two weeks, about once a month, less than once every few months?” Engagement in illegal behavior was assessed by a single question, “In the last month have you been an offender in any of the following … violent conduct, threatening behavior, property destruction, drug offenses, theft, sexual offending, fraud, motoring offenses (Yes/No)? These questions were devised to capture behavioral changes over time. Clinical Outcomes in Routine Evaluation (CORE). (Evans et al., 2000) consists of 34 items of psychological and psychosomatic strain. Dimensions are subjective well-being, problems or symptoms, life functioning, and six risk items used as clinical indicators of being “at risk” to self or others over the last week. Participants respond on a five-point scale, ranging from “not at all” to “most or all of the time.”

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Hospital Anxiety and Depression Scale (HADS). The 14-item selfreport HADS (Zigmond & Snaith, 1983) assesses depressive and anxiety symptomatology over the last week using a four-point frequency scale and provides two subscale scores for anxiety symptoms and depressive symptoms. PTSD Checklist (PCL-C). The PCL-C (Blanchard, Jones-Alexander, & Buckley, 1996) is a self-report 17-item standardized questionnaire which assesses posttraumatic symptoms (e.g., intrusive memories) over the last week. Participants respond in a five-point scale, ranging from “not at all” to “extreme” over the past month. An overall score and sub-scores for re-experience, avoidance, and hyperarousal subscales are provided. Dissociative Experiences Scale (DES). The DES (Bernstein & Putnam, 1986) is a 28-item self-report measure of the frequency of dissociative symptoms (e.g., gaps in awareness, depersonalization). Respondents rate the percentage of time (0 to 100%) they experience each symptom/item. No time frame for assessment is specified. Rosenberg Self-Esteem Scale (RSES). The RSES (Rosenberg, 1965) is a 10-item standardized self-report measure of self-esteem; no time frame for assessment is specified. Respondents report feelings about themselves using a four-point response format (strongly agree, agree, disagree, and strongly disagree). Satisfaction With Life Scale (SWLS). The 5-item SWLS (Diener, Emmons, Larson, & Griffin, 1985) assesses general life satisfaction. Respondents rate their level of agreement with each item on a seven-point scale at no specified time frame. The higher the score (range 5–35), the higher the level of life satisfaction. Qualitative Data

Qualitative data were also collected to supplement and explain quantitative data and for information on patient experience of this new intervention (i.e., acceptability). After the intervention, eight completers and eight non-completers were invited to a brief one-off qualitative interview, using a semi-structured interview schedule. The interview cohort was selected to reflect variation in basic demographics and severity of psychological difficulties. The interview focused on positive and negative aspects of using



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the workbook in a group setting, perceived changes/improvements in symptoms and day-to-day function, and general outlook. Also solicited were factors that enabled/inhibited positive change and suggestions for improving the workbook and the sessions. Data Analysis

Means (standard deviations; SDs) were calculated for all continuous variables and frequencies (%) for all categorical variables (Tables 1–4). Comparisons between pre- and post-treatment scores and between pre-treatment and follow-up scores were made by means of t-tests, and c2 analysis (Tables 2–4). Intent to treat (LastObservation-Carried-Forward; LOCF) and completers analysis were performed. A completers only analysis was performed for lifestyle questions (Table 3) because of the low number of participants who reported presence of such behaviors. Some missing data are also apparent in Table 3. Treatment effect sizes for preversus post-treatment and pre- versus follow-up for all outcome measures were calculated using Cohen’s d formula (Cohen, 1988) (Table 2). Qualitative data was subjected to interpretative phenomenological analysis (IPA), which is a method seeking to capture the experiences and meanings of participants and identify key themes (Flowers et al., 2006). Analysis was supported by the use of computer software suitable for the management and analysis of qualitative data (i.e., Nvivo). Only a summary of qualitative findings is presented in this report. RESULTS Attrition Rates

Fifty-five participants were eligible for the study, consented to participate, and entered the eight-week waiting list period. Eighty participants across all sites were invited but refused participation for a number of reasons (e.g., preference for individual work). Eighteen individuals dropped out while on the waiting list and 37 individuals entered treatment. Of the 37 who entered, 16 with-

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Figure 1. Attrition Rates

drew prior to post-treatment assessment and 21 participants were assessed. Of these 21, 6 failed to return their follow-up assessments (see Figure 1). Participants received a mean of 5.7 (SD = 3.0) sessions. A proportion of 43% dropped out before treatment completion. Completers (n = 21) and non-completers (n = 16) were compared in relation to all outcome measures at pre-intervention. It is notable that non-completers presented with more severe scores across some outcome measures at pre-intervention. Non-completers scored significantly higher in CORE Risk (t = –3.8, df = 31, p ≤ .001), CORE total (t = –2.2, df = 31, p ≤ .05), and PCL Avoidance (t = –2.3, df = 32, p ≤ .05) compared to completers. Completers and non-completers did not differ in behavioral measures such as self-harming, drinking, or using illicit substances at pre-intervention. However, a statistically significant higher percentage of



GROUP PSYCHOEDUCATION FOR SURVIVORS OF CHILD SEX ABUSE 503 Table 1. Demographic and Trauma Characteristics of Sample n = 37

Factor

Mean or nos. (SD or %) Age

38.3 (11.3)

Gender Male

4 (10.8%)

Female

33 (89.2%)

Education Basic Education

16 (43.2%)

Higher Education

21 (56.8%)

Employment Full/part-time

16 (43.2%)

Unemployed/retired/other

21 (56.8%)

Marital status Married/Cohabiting

14 (37.8%)

Divorced/Single

23 (62.2%)

Living arrangement Alone

14 (37.8%)

With others

23 (62.2%)

Currently on psychotropic medication Yes

13 (35.1%)

No

24 (64.9%)

non-completers described themselves as smokers (n = 9, 64.3%) as opposed to nonsmokers (n = 5, 35.7%) (c2 = 5.7, df = 1, p ≤ .05). Sample Characteristics

As shown in Table 1, mean age of participants was 38.3 (SD = 11.3). The majority were female (89.2%), they had attended higher education (56.8%), but they were unemployed or retired (56.8%). Also, the majority reported they were divorced or single (62.2%) and were living with others (62.2%). Finally, the majority (64.9%) reported they were not on psychotropic medication at the time of study.

2.7 (0.8)

2.6 (0.8)

2.6 (0.8)

Well-being

2.1 (0.7)

2.1 (0.8)

18.1 (4.4)

58.3 (14.5)

Hyperarousal

Total

16.5 (4.8)

31.2 (19.3)

27.9 (16.7)

24.9 (2.5)

13.2 (6.5)

DES

RSES

SWLS 12.5 (5.6)

24.2 (2.4)

32.4 (18.9)

10.4 (4.7)

14.0 (3.4)

58.2 (12.3)

18.7 (4.2)

22.3 (5.3)

17.4 (5.0)

2.0 (0.8)

0.8 (1.0)

2.0 (0.8)

2.5 (0.8)

2.5 (0.9)

Postintervention

t = 0.2, n.s

t = 0.4, n.s

t = 1.0, n.s

t = 1.3, n.s

t = 0.1, n.s

t = –0.8, n.s

t = 0.6, n.s

t = –0.7, n.s

t = 1.3, n.s

t = 1.0, n.s

t = 0.6, n.s

t = 1.3, n.s

t = –1.1, n.s

t = 1.0, n.s

df = 36

Pre-post Comparison

–0.1

0.1

–0.1

0.1

0.1

–0.1

–0.1

–0.1

–0.1

0.1

0.1

0.2

0.1

0.1

Cohen’s d

12.7 (6.0)

24.2 (2.3)

31.2 (19.3)

10.9 (5.4)

14.2 (4.1)

57.6 (14.7)

18.7 (4.8)

22.3 (6.2)

16.6 (5.4)

2.2 (0.8)

0.9 (1.0)

2.2 (0.9)

2.6 (0.9)

2.7 (0.9)

Follow-up

t = 0.4, n.s t = 0.5, n.s

–0.1

t = 0.5, n.s

t = –0.7, n.s

t = 0.1, n.s

t = –0.5, n.s

t = 0.5, n.s

t = – 0.8, n.s

t = 0.2, n.s

t = –0.1, n.s

t = 1.2, n.s

t = – 0.2, n.s

t = –0.5, n.s

t = – 0.1, n.s

df = 36

Pre-follow-up Comparison

0.1

0.1

–0.1

0.1

–0.1

–0.1

–0.1

–0.1

–0.1

–0.1

0.1

–0.1

–0.1

Cohen’s d

Note. Cohen (1988) provides the following guidelines for interpreting effect size d: “small, d = .2,” “medium, d = .5,” and “large, d = .8.”

12.4 (6.0)

24.3 (2.2)

10.5 (4.6)

13.9 (3.8)

11.0 (5.0)

Anxiety

14.2 (3.8)

56.7 (13.5)

18.2(4.6)

21.9 (5.6)

Depression

HADS

17.1 (5.2)

23.1 (6.2)

Re-experience

Avoidance

PCL-C

Total

0.8 (1.0)

0.8 (0.9)

Risk

2.2 (0.8)

2.6 (0.9)

2.2 (0.8)

Symptoms

Functioning

CORE

Baseline

Measure

Preintervention

Table 2. Baseline, Pre-, Post-, and Follow-Up Means (SDs) of Outcome Measures (Intention to Treat Analysis)

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Intervention Outcomes: Psychopathology, Self-Esteem, and Life Satisfaction

Table 2 illustrates means and standard deviations at baseline, pre-intervention, post-intervention, and follow-up on all outcome measures. In intention to treat analysis, there were no statistically significant differences (p ≤ .05) between baseline and pretreatment scores across all outcome measures, suggesting lack of natural recovery over time. As shown in table 2, there were no statistically significant (p ≤ .05) changes over time from preto post-treatment and pre- to follow-up across all outcome measures. Treatment effect sizes were small (d ≤ .20) (Cohen, 1988) across outcome measures and assessment points. A completer’s only analysis confirmed these findings at both post-treatment and follow-up. In line with intervention goals, these results indicate that the new psychoeducational intervention did not have any effect on clinical improvement with regard to general psychological distress, traumatic symptomatology, anxiety, depression, dissociation, self-esteem, and life satisfaction. Intervention Outcomes: Self-Harm and Substance Use Patterns

Table 3 illustrates self-harm and substance misuse patterns across all four assessment points. From baseline to pre-treatment, no major changes were observed with regard to self-harm and substance misuse patterns. From pre- to post-intervention, a significantly (p ≤ .001) lower number of participants reported selfharming. This trend continued at follow-up (p ≤ .001). However, there were no differences in the numbers of those who reported regular self-harming from pre- to post-intervention. From pre- to post-intervention, a significantly lower number of participants reported smoking. Those who reported they were smokers during the intervention period also reported smoking a greater number of cigarettes at post-intervention, although these differences were not statistically significant. With regard to alcohol consumption, a significantly lower number of participants reported consumption of alcohol from pre- to post-intervention (p ≤ .001), although those who reported alcohol consumption also reported that they

3 (14.3%) 18 (85.7%) 1 (33.3%)

26 (72.2%) 10 (27.8%) 7 (26.9%) 19 (73.1%) 10.5 (12.1) 6 (17.1%) 29 (82.9%) 2 (33.3%) 4 (76.7%)

6 (42.9%) 8 (57.1%) 14.2 (17.9)

22 (61.1%) 16.3 (6.7)

No 21 (61.8%) Number of cigarettes per day 18.8 (11.1) Alcohol consumption Yes 26 (76.5%) No 8 (23.5%) Frequency of alcohol consumption At least once a week 5 (19.2%) Less than once a week 21 (80.8%) Alcohol units per week 9.4 (14.6) Use of illicit substances Yes 4 (11.8%) No 30 (88.2%) Frequency of illicit substances consumption At least once a week 1 (25%) 3 (75%)

14 (66.7%) 7 (33.3%)

14 (38.9%)

13 (38.2%)

Less than once a week

14 (66.7%) 18.3 (10.7)

2 (25%) 6 (75%)

2 (25%) 6 (75%)

2 (66.7%)

7 (33.3%)

2 (66.7%) 1 (33.3%)

3 (13.6%) 19 (86.4%)

8 (22.2%) 28 (77.8%)

8 (23.5%) 26 (76.5%)

Post- intervention

Pre- intervention

Baseline

Measure Self-Harm Yes No Self-harm frequency At least once a week Once a month or less Smoking Yes

1 (7.1%) 13 (92.9%)

X2(1) = 20.0, p ≤ .001

Low frequencies

1 (100%)

0

5 (41.7%) 7 (58.3%) 5.4 (5.7)

X2(1) = 10.4, p ≤ .001 t(8) = –1.3, n.s

12 (80%) 3 (20%)

X2(1) = 13.1, p ≤ .001

13 (86.7%) 8.0 (0.1)

2 (13.3%)

X2(1) = 13.1, p ≤ .001 t(4) = –1.0, n.s

1 (100%) 0

2 (13.3%) 13 (86.7%)

Follow-up

Low frequencies

X2(1) = 21.0, p ≤ .001

Pre-post Comparison (df )

Low frequencies

X2(1) = 13.0 p ≤ .001

t(6) = –2.1, n.s

X2(1)) = 4.9, p ≤ .05

X2(1) = 10.3, p ≤ .001

SE dif = 0

X2(1) = 15.0, p ≤ .001

Low frequencies

X2(1) = 21.0, p ≤ .001

Pre-follow-up Comparison

Table 3. Baseline, Pre-, Post-, and Follow-Up Means (SDs) and Changes Over Time of Lifestyle Questions (Completers Analysis)

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consumed more units of alcohol from pre- to post-intervention. These differences were not statistically significant (p ≤ .05). With regard to frequency of alcohol consumption, one less individual reported regular alcohol use (at least once a week) at post-treatment. These differences were statistically significant (p ≤ .001). Finally, a significantly lower number of participants reported use of illicit substances at post-treatment compared to pre-intervention (p ≤ .001). One less individual reported frequent use of illicit substances at post-treatment. Positive changes were maintained at 3-month follow-up with regard to self-harming, smoking and number of cigarettes per day, use of alcohol, frequency of alcohol consumption and number of alcohol units per week, use of illicit substances, and frequency of illicit substances consumption. Overall, these results indicate that treatment completers were less likely to report self-harm and substance misuse at postintervention and follow-up. Intervention Outcomes: Antisocial and Illegal Behavior

None of the participants reported involvement in drug offenses or being a perpetrator of theft, sexual offense, fraud, or motoring offenses at baseline. This trend was maintained at all assessment points with the exception of drug offenses, where one individual reported involvement in drug offenses at pre-intervention. From baseline to pre-treatment, no major changes were observed in patterns of antisocial and illegal behavior, although two fewer individuals reported involvement in violent conduct and one additional individual reported involvement in drug offenses at pretreatment. With regard to violent conduct, four (11.8%) participants reported violent conduct at baseline and two participants (5.7%) at pre-intervention. No individuals reported violent conduct at post-intervention or follow-up. A total of five (14.7%) participants reported threatening behavior at baseline and four participants (11.4%) at pre-intervention. No participants reported threatening behavior at post-intervention or follow-up. Three participants (8.8%) reported that they had engaged in property destruction prior to baseline assessment and two (5.7%) individuals a month prior to pre-intervention assessment. No participants reported

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property destruction at post-intervention and 3-month follow-up. Overall, these results indicate that those who stayed in the program seemed less likely to report antisocial and illegal behavior at post-intervention and follow-up. Summary of Qualitative Results

Both completers and non-completers reported having felt apprehensive before starting the program, due to the uncertainty and anticipated difficulties with group work. However, despite initial apprehension, the majority of completers enjoyed the program and reported benefits from it. With regard to benefits, many completers identified acceptance of the reality of the abuse as a key achievement during the program. They also saw the program as a learning experience. Many completers claimed that the program helped them to find explanations for persistent feelings and behavior patterns which had puzzled them in the past. For many completers, the groups seemed to provide peer support, acknowledgement, and normalization of their experiences and feelings, as well as validation within a safe environment. Non-completers reported that the program did not meet their expectations (i.e., group therapy involving trauma-processing work), so they dropped out due to disappointment. They also highlighted how a mismatch between their own and their peers’ assumptions often spoiled the program experience for them. Some non-completers expressed a preference for and expectation of a more therapeutic emphasis in the program. Others, however, preferred an educational emphasis but claimed to have often felt disconnected with parts of the material not directly relevant to their experience and needs. Thus, for some non-completers, a more personalized focus would have been welcome. Nevertheless, non-completers agreed that the generic character of the material was necessary to appeal to a range of individuals and personal circumstances. Similar to completers, some noncompleters claimed that the program cultivated a sense of belonging and helped them break isolation and get to know themselves. However, other non-completers described their struggle to fit in and connect with the group, something attributed to a



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mismatch between their stage in the recovery journey and that of their group peers. They also described their reluctance to associate themselves with a victim identity, often dominant within the group. Finally, non-completers often talked about their pattern of “walking away” from help, which underpinned their history of help-seeking prior to the program. DISCUSSION

The present study reports on the effectiveness and acceptability of a new psychoeducational intervention for survivors of CSA. Preliminary results indicate that the new intervention may be useful for stabilizing behavioral problems at post-treatment and follow-up. High dropout rates (43%) were found in the present study although these are quite similar to previous research in the area of psychological interventions for traumatized populations in Scotland (e.g., 43.5% in Karatzias et al., 2011). Nevertheless, it is notable that dropout rates in the present study are higher than rates reported in previous relevant research. Dropout rates ranged between 4% (Wright et al., 2003) to 34% (Morgan & Cummings, 1999) across studies which evaluated similar psychoeducation programs. The high dropout rates may call into question the validity of the present findings, which require replication in future research. However, these findings are consistent with the high dropout rates we observe in clinical practice with survivors of childhood trauma. In addition, there is evidence to suggest that the presence of a personality disorder is associated with high dropout rates (Swift & Greenberg, 2012) in psychotherapy, and survivors of CSA are at high risk for personality disorders (Moran et al., 2011). Our qualitative data also revealed that for many completers there was a mismatch between their stage in the recovery journey and that of their peers in the group. For those survivors, individual approaches might have been more appropriate. It was also notable that non-completers did not appreciate the didactic nature of the program, and they presented with more severe psychopathology at pre-treatment in a number of measures, including traumatic avoidance. These findings indicate that a more careful selection of participants for group programs is nec-

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essary to minimize the risk of dropout. Careful assessment prior to the intervention, including assessment of appropriateness to cope with its demands, and a preparatory session for group psychotherapy may facilitate adjustment in a group setting. It is notable that the present intervention produced less favorable outcomes with regard to psychopathology outcomes compared to previous research. Previous research has demonstrated that group psychoeducational interventions are beneficial at posttreatment and follow-up assessments for addressing traumatic symptoms (e.g., Dorrepaal et al., 2010), depression (e.g., Morgan & Cummings, 1999), dissociation (e.g., Zlotnick et al., 1997), and general psychopathology (e.g., Stalker & Fry, 1999). However, the focus of the intervention in this study was on safety, stabilization, and stress management skills as opposed to treating mental health problems. Our qualitative data suggest that program completers saw benefits in these areas. However, it would be useful to include measures of distress tolerance, coping strategies, and emotional regulation as outcome measures and not focus exclusively on psychopathological measures. Preliminary evidence from the present study also suggests that psychoeducational interventions are helpful in stabilizing behavioral outcomes such as self-harm and substance misuse in CSA survivors. However, it is important to emphasize that information on self-harm and substance misuse has been collected using self-rated and non – validated measures. Nevertheless, there were significant differences between interventions employed in previous research and the present one in duration, intensity, and frequency of sessions. In previous studies, psychoeducational group interventions were of higher intensity and longer duration than “Survive & Thrive.” For example, some previous interventions tested were intensive inpatient group programs (e.g., Wright et al., 2003). In some instances, group therapy was augmented by individual therapy (Dorrepaal et al., 2010). The present study was one of the very few group psychoeducational interventions exclusively delivered to adult CSA survivors, uncontaminated by other types of trauma. Many previous studies incorporated survivors with various traumatic experiences. Our findings require replication in adequately powered studies. Sample size was rather small although measures of control (e.g.,



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waiting list period prior to intervention, wide range of outcomes tested) were exercised. Another methodological limitation of the present study was its lack of a control group to demonstrate that an intervention is better than no intervention (Stevens, Hynan, & Allen, 2000). However, to compensate for this, a waiting period of eight weeks was introduced prior to the commencement of treatment. There were no statistically significant differences between baseline and pre-treatment scores on any of the outcome measures. It was also one of the strengths of the present study that data were collected on the acceptability of the intervention from both the professionals who delivered the program and completer and non-completer participants. Finally, the predominance of female participants also limits the generalizibility of findings to men. Despite its limitations, the present study has produced some preliminary evidence that brief group psychoeducation may be beneficial for CSA survivors, as a stage 1 intervention. Participating in an intervention group that is safe and respectful can enable survivors to explore the impact of their trauma by hearing and being heard by other survivors and by tackling powerlessness and social disengagement. Eventually, survivors can rebuild a sense of self and also achieve interpersonal growth (Mendelsohn, Zachary, & Harney, 2007). Further, group interventions provide opportunities for experiential learning that many survivors might have been denied early in life (e.g., emotion regulation), challenge a commonly held assumption that they have been affected by the trauma in a unique and profound way, and facilitate the development of interpersonal skills (e.g., dealing with rejection and trusting others). At a service level, group therapy is more efficient than individual therapy because it can be offered broadly; it is therefore more cost-effective and can help reduce long waiting lists (Courtois & Ford, 2009). Despite these presumed benefits, the evidence supporting the effectiveness of group psychotherapy for survivors of complex trauma has been scarce. Therefore, further research in the area is required, particularly on the effectiveness of stage 2 and 3 group interventions. Future research on the effectiveness of psychoeducational interventions should also focus on the effects of group psychoeducation on interpersonal and emotional regulation outcomes.

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