La thérapie des schémas est-elle pertinente pour une population adulte souffrant de TSPT et de TSPT-complexe ? Une revue de littérature systématique qualitative

Abstract

Context

Schema therapy (ST) involves two core concepts: early maladaptive schemas and modes. Early maladaptive schemas play a key role in the development and maintenance of post-traumatic stress disorder (PTSD), while observed modes reflect the internalized relationships of the traumatized individual. Given this context, how might ST be an interesting psychotherapeutic approach for a population suffering from PTSD or complex post-traumatic stress disorder (CPTSD)?

Objectives

Considering the impact of trauma and/or adversity on the subject's psychological development, ST could be relevant for a population suffering from PTSD or CPTSD. This study aims to explore the effectiveness of ST in treating an adult population suffering from PTSD or CPTSD, through a review of qualitative literature.

Methods

Following the PRISMA guidelines, articles were searched from December 2023 to May 2024 on PubMed, Google Scholar, PsycInfo, and the Cochrane Library, with specific eligibility criteria: studies on ST, adult population with PTSD or CPTSD, with no publication year limit. Data extraction considered the studied pathology (PTSD or CPTSD), research methodology, therapeutic setting (group/individual), measurement tools, and therapy effects.

Results

Numerous studies explore the early maladaptive schemas of traumatized individuals, while others observe the effectiveness of ST in various clinical populations. However, few studies focus specifically on PTSD or CPTSD. The research process, summarized in a flow diagram, identified 989 articles, of which twelve were selected and analyzed, involving for 302 participants. Given the predominantly qualitative nature of the studies, a qualitative synthesis was deemed appropriate. Researchers’ chosen diagnoses varied according to the nosographic reference (DSM-5 for PTSD, ICD-11 for CPTSD). ST was found to reduce post-traumatic symptoms but also impacts overall psychiatric symptoms, anxiety, depression, suicidal thoughts, and the severity of substance and/or alcohol addiction. Improvements were observed in overall functioning, emotional regulation, interpersonal relationships, socio-professional life, quality of life, and self-esteem. ST is found to be relevant when exposure therapy was ineffective for trauma treatment.

Research methodologies vary

Quantitative studies demonstrated ST's effectiveness, while case studies explore the process of change at work in therapy and ST's efficacy. Some biases were noted, particularly in session transcription practices, the small number of comparison groups, and the absence of independent evaluations. Psychotherapeutic interventions included individual and/or group-based approaches, utilizing cognitive, behavioral, and experiential tools, including imagery rescripting or chair work. Only one study adapted its group therapy content to the three-phase approach recommended in psychotraumatology. As an integrative approach, some researchers innovatively combined ST with Eye Movement Desensitization and Reprocessing (EMDR) to address traumatic and addiction memories or with psychoanalysis to work on dreams through imagery rescripting.

Discussion

Several discussion points were explored. Contemporary psychotraumatology and its theoretical foundations, particularly the concepts of dissociation and integration, could enrich ST work for the studied population. Studying common factors, particularly the therapeutic alliance, would further illuminate the psychotherapeutic process, given ST's emphasis on the therapeutic relationship and attachment. Group therapy seems to reawaken previous family issues, with emotional regulation strategies implemented within the group. Examining group cohesion quality would clarify individual and group psychotherapeutic progress. Finally, contextual ST, integrating acceptance and commitment therapy principles, remains an unexplored avenue with this population.

Conclusion

To bridge the gap between research and practice, action research in ST, combining individual and group therapy for CPTSD patients, would enhance understanding of the mechanisms of change within this therapeutic model.