Four practice-based preliminary studies on Human Givens Rewind treatment for posttraumatic stress in Great Britain

Evidence for effectiveness in practice-based studies

At present, the evidence for the effectiveness of Rewind is based on practice-based evidence. A literature review by Corps et al. (2008) only found individual case descriptions and two wider studies. The first of these studies by Guy & Guy (2003) reported on all those treated with Rewind during a specified period (N=30), with 40% rating the treatment as ‘extremely successful’, 53% rating it as ‘successful’, 7% rating it as acceptable, and no one rating the treatment as ‘poor’ or ‘a failure’. However, they did not use standardised questionnaires. The second of these studies by Murphy (2007) used a qualitative methodology to explore the effectiveness of a single Rewind treatment session. All those treated with Rewind at a trauma clinic were included (N=47). He reported that all those treated experienced symptom reduction with none meeting the criteria for PTSD after treatment, whether treated for single or multiple traumas. He also reported the Rewind could be used successfully as a standalone treatment or in conjunction with other treatments. Results from a more recent qualitative study using a single Rewind treatment session suggested that Rewind treatment may make treatment more accessible for shame-based traumas as details of the traumas do not need to be discussed during the treatment (Adams, 2017, pp. 136–141). A later uncontrolled study by Guy & Guy (2009) reported on 97 clients treated with the single HG Rewind treatment session. Mean scores on the Impact of Events Scale – Extended version (IES-E; Tehrani et al., 2002) reduced from 68 pre-treatment (the severe range) to 18 post-treatment (the normal range). However, only the pre- and post-treatment data were provided with no indication of effect sizes or standard deviations, making it difficult to compare their findings with other studies. Burdett & Greenberg (2019) reported 52% (N=504) of war veterans with planned endings treated with Human Givens therapy (42% of the whole sample) were below the clinical cut-off of 11 on Clinical Outcomes in Routine Evaluation (CORE-10; Connell & Barkham, 2007) after treatment. Of these, 42% attended more that one session and 5% attended 6 or more sessions. In a separate study comparing a single Rewind session with a treatment-as-usual session, data capture rates, means and effect sizes, as well as ‘reliable improvement’ and ‘recovery rates’ were reported (Adams & Allan, 2019b). After a single Rewind session (N=44), 38% were below the clinical cut-off of 11 on CORE-10, with a pre-post effect size of 1.86.

Three studies have explored the effectiveness of HG therapy overall, have been reported (Andrews et al., 2011; Andrews et al., 2013; Tsaroucha et al., 2012). None of these three studies reported how many clients were treated with the Rewind technique. The first two of these studies were large trans diagnostic practice based studies that reported effect sizes as well as ‘recovery rates’ and ‘reliable improvement rates’ in line with the IAPT protocol (Clark et al., 2009). The Andrews et al. (2011) practice-based study included 3 therapists and 124 clients while the Andrews et al. (2013) study included 46 therapists at multiple sites, with 3,885 clients. Treatment was completed in an average of 3.75 treatment sessions (Andrews et al., 2011) and 4.69 treatment sessions (Andrews et al., 2013), excluding the initial assessment session. The pre-post treatment effect sizes were 1.39 (Andrews et al., 2011) and 1.58 (Andrews et al., 2013), both slightly above the IAPT effect size of 1.22 (Clark et al., 2009). Tsaroucha et al. (2012) compared HG treatment for depression with a treatment-as-usual control group in a non-randomised study and reported similar improvement rates between treatment groups but HG therapy requiring an average of 2 rather than 4 treatment sessions to achieve similar results. Thus, there is some preliminary evidence that HG therapy may be a promising treatment but it is unclear how frequently the Rewind technique was utilised in these studies.

In summary, Rewind is a relatively new treatment for PTS in which the trauma does not need to be discussed in detail and multiple traumas can be treated in one session. HG therapy that incorporates the Rewind technique may require fewer sessions and therefore might be cost effective, but more research is needed to record the number of treatment sessions for PTS. Practice-based evidence across different treatment settings has evolved to report ‘recovery rates’ and ‘reliable improvement’ as well as pre-post treatment effect sizes, and practice-based data capture rates have improved by using questionnaires in every session (see Clark et al., 2009). However, this data has not been consistently reported in previous Rewind studies and those earlier findings have yet to be replicated in different treatment settings.

This paper briefly describes the evidence from four practice-based preliminary studies for HG Rewind. The aim of this paper was to attempt to replicate findings from previous preliminary studies in a variety of settings. The average number of treatment sessions, exclusion criteria, data capture rates, effect sizes, recovery rates, and reliable improvement and deterioration are reported for each study.

Design

Each of the four studies were observational prospective cohort studies. A session-by-session monitoring system was used where clients were asked to complete the questionnaires in every session in order to provide greater data capture rates (Clark et al., 2009; Gillespie et al., 2002). The scores from the last treatment session were used as the ‘end of treatment’ score.

Statistical analysis

Means, standard deviations and effect size were reported for each study. Cohen’s d was used to calculate the effect size, subtracting the post-treatment mean from the pre-treatment mean and dividing the outcome by the pooled standard deviation (Clark et al., 2009) using Microsoft Excel. Effect sizes were interpreted using Cohen’s (1988) suggested convention of 0.2 indicating a small, 0.5 a medium, and 0.8 a large effect size.

A within-subject analysis was used to calculate ‘recovery rates’, ‘reliable improvement rates’, ‘no reliable change rates, and ‘reliable deterioration rates’. These measures of effectiveness (IAPT, 2012) have become more popular as IAPT has become established in Great Britain. ‘Recovery’ was defined as scores below the clinical cut-off on standardised questionnaires at the end of treatment. Participants were categorised as having ‘reliable improvement’, ‘no reliable change’, or ‘reliable deterioration’ using the Reliable Change Index (RCI) for each questionnaire. The RCI refers to the amount of change that is not likely to be due to chance. The RCI was calculated for those scales where the RCI was unknown using the Jacobson & Truax (1991) formula.

Intervention: Brief description of the Rewind technique

The Rewind technique involves graded imaginal exposure to the trauma(s), while keeping arousal levels relatively low. The Griffin & Tyrrell (2001) protocol was used. For a more detailed description and discussion of HG Rewind, see Adams & Allan (2019a). HG Rewind has several stages:

1.  Preparation and activation of the trauma memory. The therapist briefly explains the procedure and helps the client create an imaginary ‘video’ that will be used later in the process. The video starts with a good memory. Then for each trauma or trigger, the video starts before and ends when the incident is over, and then the video ends with a recent good memory.

2.  Relaxation. The therapist guides the client to become deeply relaxed. This includes imagining being in a relaxed place.

3.  Double distancing exposure. In their imagination, the client watches themselves watch the imaginary ‘video’ backwards and forwards until they feel calm when watching themselves.

4.  Single distancing exposure and association exposure. The client watches the imaginary video with the trauma memories backwards and forwards until they are calm when watching it. For the association exposure, the client is then guided to re-experience all of the trauma sensations very quickly backwards by imagining they are being pulled backwards very quickly through the memory from when the trauma was over to the beginning before the trauma started. This is repeated until the scenes evoke no anxiety.

5.  Rehearsal (optional). If relevant, the client is asked to visualize themself reacting to a similar situation in the future in a way that the client would like to respond.

6.  End. The client is re-oriented to the present.

Procedure and measures

The procedures and measures used in each study are described below. Data collected at each of the sites was part of the routine clinical care, and as such did not require ethical approval from the University of Leicester. However, all participants provided informed consent for their anonymised data to be used to study the effectiveness of their treatment.

STUDY 1: Rewind treatment outcomes for staff in a police force

The purpose of this preliminary study was to investigate the effectiveness of the Rewind treatment for PTS in a police force setting. Officers and staff in the police force were referred for treatment by the Occupational Health advisors, and all those who were referred were treated with no exclusion criteria. Any staff with a possible diagnosis of PTSD were first be seen by the Forces Medical Advisor for a diagnosis before making the referral for Rewind treatment. All the clients treated using the Rewind technique in a specific police force between 2009 and 2013 were included. All those treated by the service completed the CORE-OM before and after treatment. Those with a diagnosis of PTSD or PTS were also given the IES-R before and after treatment. The Griffin & Tyrrell (2004) HG treatment was used with the Griffin & Tyrrell (2001) protocol for the Rewind technique.

Impact of Events Scale – Revised version (IES-R). The IES-R is a modified version of the IES (Horowitz et al., 1979), and is a questionnaire designed to measure symptoms of traumatic stress. The IES has an avoidance and intrusion subscale. Weiss & Marmar (1997) added an intrusion subscale with seven additional items as part of the IES-R to conform with DSM IV (APA, 1994) PTSD criteria. There are ‘avoidance’, ‘hyper-arousal’, and ‘intrusion’ subscales that are added together to give a total score. In the IES-R, the respondent answers the question in relation to the impact of a specific traumatic event on symptoms using a 0–4 rating scale. The IES-R has 22 items and can generate a total score of 88. A clinical cut-off of 33 has been established (Creamer et al., 2003). The RCI for the IES-R is 9 (IAPT, 2011).

Clinical Outcomes for Routine Evaluation (CORE-OM). The CORE-OM was designed in the UK by Evans et al. (2000) to measure outcomes for psychological therapies. It is a 34-item questionnaire, where items are scored from 0–4 over the past week, and cover subjective well-being, symptoms, functioning, and risk. It has good internal consistency and test-retest reliability (Evans et al., 2002). Scores of 8.5–12.5 are mild, 12.75 – 16.75 are moderate, 17–21 are moderate to severe, with scores over 21 considered to be severe. An RCI on the CORE-OM is 5 or more (Connell & Barkham, 2007). The recommended cut-off between clinical and non-clinical populations for the CORE-OM is 10 (Connell et al., 2007).

STUDY 2: Treatment outcomes for war veterans

The purpose of this preliminary study was to investigate the effectiveness of the Rewind treatment for war veterans suffering from PTS in clinical settings using 43 therapists. All war veterans who self-referred between 24 April, 2014 and 14 January, 2015 for treatment to a national war veteran charity providing HG therapy were included. The charity then referred the veterans to fully qualified and registered local HG therapists. The charity registered clients online on the Pragmatic Research Tracker when the referral was made, ensuring all those referred to the service were eligible to be included. HG therapy included the Griffin & Tyrrell (2001) Rewind treatment protocol for trauma. All the therapists were trained HG therapists and on the HG national register.

Impact of Events Scale –Extended Version (IES-E). The IES-E is a modified version of the Impact of Events Scale (IES; Horowitz et al., 1979). Tehrani et al. (2002) modified the IES by adding a question about sleep to the ‘intrusion’ subscale and adding a ‘hyper-arousal’ subscale to make it more in line with the DSM IV (APA, 1994) PTSD criterion. The respondent answers the questions in relation to the impact of a specific traumatic event on symptoms on a 0–4 rating scale. There are ‘avoidance’, ‘hyper-arousal’, and ‘intrusion’ subscales which are added together to give a total score. There are 23 items and the maximum score is 92. Using a UK sample, Tehrani et al. (2002) found the reliability and discriminant validity of the IES-E to be good. The mean Cronbach’s alpha for the three subscales was 0.92, and the standard deviation from the norm was 12.6. Using the Jacobson & Truax (1991) formula, the RCI for the IES-E is 6. Tehrani et al. (2010) determined the clinical cut-off for PTSD for the IES-E was 50 and above, with scores of 40–49 indicating moderate symptoms still requiring treatment, scores of 30–39 indicating mild symptoms, and scores of less than 30 being in the normal range.

Clinical Outcomes in Routine Evaluation (CORE-10). The CORE-10 (Connell & Barkham, 2007) is a brief 10 item standardised questionnaire measuring psychological distress that is based on the longer 34 item CORE-OM (Barkham et al., 2001). Each self-report item is rated on a 0–4 scale, with a total score of 40. CORE-10 has a high correlation with CORE-OM (Adams, 2017; Andrews et al., 2011; Andrews et al., 2013). The clinical cut-off for CORE-10 is 11, with the specific cut-off for depression of 13 (Barkham et al., 2013; IAPT, 2011). The RCI is 6 or more (Barkham et al., 2013).

STUDY 3: Rewind treatment in a private PTSD treatment clinic

The purpose of this preliminary study was to examine the clinical effectiveness of a single Rewind session to treat PTS in a clinical setting. All clients who were referred to the PTSD treatment clinic between 2009 and 2014 were included and accepted for treatment with no exclusion criteria. The Griffin & Tyrrell (2001) Rewind protocol for treating trauma was used. This treatment session was part of the HG therapy that they received. The Impact of Events Scale –Extended Version (IES-E) was administered to clients before the Rewind treatment session and in the follow-up session, 1–2 weeks after the treatment.

Impact of Events Scale –Extended Version (IES-E). See above.

STUDY 4: Rewind treatment in a private practice

The purpose was to evaluate the effectiveness of HG therapy for treating PTS in a fourth clinical setting. All clients who were referred to this private practice were treated with Rewind between February 2010 and February 2015 were eligible for inclusion in this study. Of the 113 clients treated during this period, 38 were treated with HG therapy without the Rewind and 75 were treated with HG therapy including Rewind. There were no exclusion criteria, with all those being referred for treatment being accepted for an assessment. The CORE-10 (study 4a) and the GAD-7 and PHQ-9 (study 4b) were administered at the assessment and at every subsequent treatment session. The questionnaires used in this practice changed during the data collection period to reflect changes in practice in the local area. The Griffin & Tyrrell (2001) Rewind protocol was used.

Clinical Outcomes in Routine Evaluation (CORE-10). See above

Generalised Anxiety Disorder (GAD-7). The GAD-7 is a self-report questionnaire to screen and measure the severity of generalised anxiety disorder (Spitzer et al., 2006). It has 7 items that are rated on a 4 point scale. The scoring range on the GAD-7 is 0–21, with scores of 15–21 indicating severe anxiety, scores of 11–15 indicating moderate anxiety, and scores of 5–10 indicating mild levels of anxiety. The clinical cut-off for anxiety on the GAD-7 is 8 and above, and the RCI is 4 or more (Clark & Oates, 2014)

Patient Health Questionnaire (PHQ-9). The PHQ-9 is a self-report questionnaire to screen and measure the severity of depression (Kroenke et al., 2001). It has 9 items that are rated on a 4 point scale, with scores ranging from 0–27. Scores of 20–27 indicate severe depression, scores of 15–19 indicate moderately severe depression, scores of 10–14 are in the moderate range, scores of 5–9 are in the mild range, with the clinical cut-off for depression being 10 and above. The RCI is 6 or more (Clark & Oates, 2014).

Participants

Demographics are reported in Table 1. There were approximately 30% males in two of the studies and 87% male in the war veteran study. The gender of participants in one study was unknown. The average age in the studies ranged from 39 years to 46 years, with age in one study not recorded.

Exclusion criteria, pre-assessment attrition rates and data capture rates

The client pathways for all studies, including those referred, assessed, started treatment, completed treatment and data capture rates for ‘intention-to treat’ and those who completed treatment for all studies are summarised in Table 2. Studies 1, 2, and 3 treated everyone that was assessed. Clients were excluded from these studies if they were under 18 years old (n=5) or were below the clinical cut-off before treatment commenced (n=15). The intention-to-treat data capture rates ranged from 80% to 100%. The data capture rates for those who completed treatment were 100% for three studies and 94% for Study 2.

Number of sessions

Table 1 shows the number of sessions in each study. The results for Study 3 are based on a single Rewind session, but participants had other HG therapy treatment sessions. The mean number of sessions in all the studies ranged from 5 to 6.5, with between 73% and 84% completing treatment in 6 sessions or less. The number of treatment sessions ranged from one to 24 sessions.

Means and standard deviations for pre- and post-treatment scores, effect sizes and RCIs

Results for those who completed treatment in all of the studies are presented in Table 3. This includes the number of those who completed treatment, mean and standard deviations for pre- and post-treatment scores with the clinical cut-off for that questionnaire, the mean change in scores and the RCI for the questionnaire, and the effect size. The mean pre-treatment scores were either in the severe range or in the moderately-severe range on all questionnaires. Many of the questionnaires had both a higher and a lower clinical cut-off. The mean post-treatment scores were below the higher clinical cut-off in all of the studies and below the lower clinical cut-off in Studies 1 and 4b. The change in scores for all of the studies was higher than the RCI. There was a large pre-post treatment effect size for each of the studies.

Recovery rates, reliable improvement, no reliable change and reliable deterioration

The recovery rates, reliable improvement rates, no reliable improvement and reliable deterioration for participants who completed treatment are presented in Table 4. With the trauma questionnaires, the recovery rates ranged between 45% – 52% for the lower cut-offs (normal range) and 47%–89% for the higher clinical cut-offs. Using the CORE questionnaires the recovery rates ranged from 49% – 59% for the lower clinical cut-off and 58% – 74% for the higher IAPT clinical cut-off.

The improvement rate of those who were either above the RCI or below the clinical cut-off after treatment ranged from 88% – 94% for trauma symptoms, and 83% – 96% on the other questionnaires. That is, between 9% –17% of the veterans and 4% – 13% of the other clinical groups in these studies had no ‘reliable improvement’. There was no ‘reliable deterioration’ in any of the studies.

Number of treatment sessions

These results are similar to previous studies using HG therapy. The results of Study 3 are from a single Rewind treatment session, with 45% of the sample was below the clinical cut-off of 30 on the IES-E after the Rewind treatment. Other preliminary studies have found that some clients do not require further treatment after a single Rewind session. Of those treated with Rewind in a trauma clinic in Northern Ireland (N=44), 61% of those treated were reported as only needing a single Rewind session (Murphy, 2007). Similarly, of those treated with a single Rewind session at a pilot NHS trauma clinic (N=27), 37% did not need further treatment (Adams, 2017, p.133) and in a separate study (N=44), 38% were below the clinical cut-off of 11 on the CORE-10 after a single Rewind session (Adams & Allan, 2019b). Burdett & Greenberg (2019) reported 58% (N=504) only attended one session, although it is unclear how many of these did not require further treatment. With the emphasis on cost-effective treatment the possibility of a stepped care approach to trauma treatment might be considered, with a single trauma-focussed exposure treatment being offered initially to those who might benefit from it before being stepped up to currently recommended treatments if necessary.

While a single treatment session can be effective, most clients require more than one HG treatment session. In spite of this, the mean number of HG treatment sessions in these four pilot studies ranged from 5–6.5 sessions (range 1–24 sessions). This is similar to other HG studies. Guy & Guy (2009) treated their clients in six sessions or less. Andrews et al. (2013) reported an average of 4.69 treatment sessions (N=3,885) and Andrews et al. (2011) reported an average of 3.75 treatment sessions (N=124). It is important to note that across the four studies presented here, 16–27% of these clients required more than six sessions. Burdett & Greenberg (2019) reported 5% (N=504) attended six or more sessions. Thus, although the majority of clients treated with HG therapy were treated within six treatment sessions, it is also clear that some clients require more sessions.

Effect sizes and recovery rates

The pre-post treatment effect sizes across the four studies ranged from 1.90–2.68 for those who completed treatment. This is in line with other HG studies, where the pooled effect sizes for the IES-E were 2.13 (Guy & Guy, 2009) and for the CORE-10 were 1.86 (Adams & Allan, 2019b), 1.58 (Andrews et al., 2013), and 1.39 (Andrews et al., 2011).

Recovery rates using CORE-10 in these studies ranged from 49–54%. Similarly, 56% (N=124) and 54% (N=3,885) were below the CORE-10 clinical cut-off of 11 after HG treatment (Andrews et al., 2011 and Andrews et al., 2013 respectively). For war veterans completing treatment, 52% (N=504) were below the CORE-10 clinical cutoff after treatment (Burdett & Greenberg, 2019). The IES-E clinical cut-off for PTSD is 50 and above, with scores less than 30 considered in the normal range. In Study 3, 80% were below the higher IES-E cut-off of 50 after treatment with 45% in the normal range. While these scores are not directly comparable, in Study 1, 47% were in the normal range with a score below 33 on the IES-R, and in Study 2, 52% were below the Coffey et al., (2006) IES clinical cut-off of 27 whereas 89% were below the higher IES clinical cut-off of 35 suggested by Neal et al. (1994). Nonetheless, all of these HG recovery rates exceed the UK Department of Health’s target for IAPT services of a 40% recovery rate (IAPT, 2012).

In summary, the results of these four studies seem to be in line with previous evidence for HG therapy, both in terms of outcomes and the number of sessions.

Limitations

While these studies had high data capture rates and low exclusion criteria, subjects were not randomized nor were control groups used. As such, no firm conclusions can be drawn about the effectiveness of the treatment. Data on ethnicity was not collected. Studies all relied on self-report measures. Referring parties made all PTSD diagnoses and were not part of the study protocol. In addition, not all of the participants had a PTSD diagnosis, and therefore no conclusions about PTSD treatment should be drawn from these results. There was no long-term follow-up.

Underlying data

Figshare: Timmins (2020) Study 1 data, Human Givens Rewind treatment for posttrauamtic stress in a police force, https://doi.org/10.6084/m9.figshare.11316041.v2 (Timmins, 2020).

Figshare: Andrews (2020) Study 2, Human Givens Rewind treatment of posttrauamtic stress in veterans. https://doi.org/10.6084/m9.figshare.11316032.v3 (Andrews, 2020)

Figshare: Guy (2020) Study 3 data, Human Givens Rewind treatment for posttraumatic stress and PTSD. https://doi.org/10.6084/m9.figshare.11316038.v2 (Guy, 2020).

Figshare: Barr (2020) Study 4, Human Givens Rewind treatment for posttrauamtic stress. https://doi.org/10.6084/m9.figshare.11316035.v2 (Barr, 2020).

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).