“Talking, talking, talking for me, even though it helped me understand, it didn’t heal”: informing development of a trauma-informed mindfulness intervention for supporting survivors of domestic abuse with post-traumatic stress disorder

Problem

Domestic violence and abuse (DVA) is a major public health and clinical problem experienced by 1 in 4 women. The most frequent mental health consequence of DVA is posttraumatic stress disorder (PTSD). Survivors of DVA represent a distinctive patient group due to the chronicity and complexity of their trauma and the specific impact of the DVA trauma on affect regulation, changes in consciousness, sense of self, relationships and belief systems. Evidence suggests that whilst evidence-based trauma-focussed psychological interventions for the treatment of PTSD are effective, attrition rates are high due to exposure work content, which not all participants find tolerable. In contrast to trauma-focused approaches, mindfulness-based interventions do not include exposure work and could be more acceptable to survivors of DVA. Mindfulness-based interventions have recently received increased attention within the research on PTSD. The preliminary evidence from small-scale studies is encouraging. Recent systematic review identified the need for further modification of mindfulness interventions for PTSD and further RCTs of the modified intervention with large adequately randomised samples without ongoing psychotherapy. We aimed to understand how to adapt a standard mindfulness-based cognitive therapy (MBCT) course to make it trauma-informed and acceptable for DVA survivors. We also wanted to understand how best to recruit and retain DVA survivors into a feasibility trial of trauma-informed MBCT.

Approach

We conducted semi-structured interviews with professionals delivering psychological therapies to patients with experience of trauma (n=13) and survivors of DVA who have accessed therapies (n=7). Participants were recruited through professional networks, DVA networks and snowballing. Interviews explored participants previous experience of therapies and the suitability of a mindfulness approaches for the DVA population. We also explored what adaptations would be needed to the standard MBCT manual to make this safe and acceptable for DVA survivors with PTSD. The interviews were audio-recorded, professionally transcribed and analysed using the framework method. Areas of agreement or difference within and across professional and survivor groups were put together in a framework.

Findings

We identified several key themes: time out of abusive relationship, accessing concurrent therapies, mindfulness pathway (when mindfulness may be appropriate), understanding mindfulness, relevance of mindfulness to survivors of DVA, psychological and practical readiness, orientation session and practical arrangements. Several themes demonstrated differing perspectives within and across the groups: inclusion of intervention participants with poor English, substance misuse, and suicidal ideation; timing of the mindfulness course on the recovery pathway; therapist qualifications and experience; therapist-survivor relationship.

Consequences

Qualitative findings will feed into evidence synthesis to inform co-production of a prototype trauma-informed MBCT course (TI-MBCT) in collaboration with mindfulness practitioners. The prototype TI-MBCT course will be tested in a feasibility trial to evaluate the feasibility of conducting a definitive trial on the effectiveness and cost-effectiveness of trauma-informed MBCT to reduce PTSD symptoms in DVA population.