Integrated trauma therapy found to be effective for people with co-occurring psychosis and PTSD
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New research from the Institute of Psychiatry, Psychology & Neuroscience (IoPPN) at King's College London, published in The Lancet Psychiatry, has found that people with psychosis experiencing post-traumatic stress disorder (PTSD) can benefit from a trauma-focused therapy integrated with cognitive behavioral therapy for psychosis (CBTp).
The STAR (Study of Trauma And Recovery) study, led by researchers at King's IoPPN and South London and Maudsley NHS Foundation Trust (SLaM), recruited 305 participants and is the largest multisite randomized controlled trial to date of a trauma-focused therapy for people with co-occurring diagnoses of psychosis and PTSD.
PTSD is characterized by intrusive trauma memories such as "flashbacks" and other types of re-experiencing, negative appraisals, hyperarousal and avoidance of trauma reminders. The prevalence of PTSD in people with psychosis is up to five times that in the general population, with PTSD symptoms often intertwined with psychosis symptoms such as delusions and hallucinations, and traumatic events often shaping their content.
Longstanding fears were challenged
In the past, people with psychosis have been excluded from almost all PTSD research trials, and clinicians were wary of delivering trauma-focused therapy in routine clinics for fear of making the psychosis symptoms worse. But this study showed that an integrated trauma-focused CBTp, lasting nine months, was safe and highly effective with this group.
Half of the participants who received the therapy no longer met PTSD criteria post-therapy, compared with just over 20% receiving treatment as usual, despite all participants reporting repeated and multiple traumas. A similar pattern was found for complex PTSD.
There were exceptionally low rates of disengagement from therapy (6.5%), demonstrating the therapy is highly acceptable.
Professor Emmanuelle Peters, professor of clinical psychology at King's and the study's first author, said, "It is now clear that trauma-focused therapies can be delivered safely and effectively for people with PTSD and psychosis. Our results are robust in demonstrating that this intervention, which includes working on the trauma memory directly, a focus on engagement, and a flexible approach tailored to the individual, is safe, highly acceptable and effective on a range of PTSD, psychosis, and emotional well-being outcomes."
Benefits extended beyond PTSD
Overall, participants showed significant improvements in 22 out of 27 assessed outcomes. The primary outcome, PTSD symptom severity, demonstrated a moderate-to-large effect size, with additional effects ranging from large to small across psychosis symptoms (paranoia and multisensory hallucinations), mood disorders (depression, anxiety and suicidal ideation), and psychological recovery.
Dr. Amy Hardy, reader in clinical psychology at King's and the joint last author and joint therapy lead for the study, said, "The results challenge a longstanding gap in mental health care, where people with psychosis have been excluded from trauma-focused therapies. Our findings demonstrate that this must change, to ensure those historically denied access can receive evidence-based care."
Peters leads a specialist psychological therapies team for outpatients with psychosis, the PICuP Clinic, based at SLaM. PICuP now provides trauma-focused CBTp and training in the intervention to clinicians working with individuals with psychosis, led by the STAR therapy leads, Dr. Nadine Keen (PICuP Coordinator) and Hardy (PICuP and SLaM Psychology & Psychotherapy Trauma Informed Care for Psychosis Lead), alongside people with lived experience of trauma and psychosis who received the therapy in the trial.
Push for wider rollout
Dr. Nadine Keen, STAR joint therapy lead, said, "We hope the STAR trial will be a gamechanger for the psychological treatment of this highly complex and marginalized population, motivating commissioners and services to prioritize implementation of trauma-focused CBTp. This therapy can transform lives and underscores an ethical imperative: Clinical services and research should not inadvertently perpetuate trauma survivors' silence through exclusion."
Over 120 people in five U.K. sites (London, Manchester, Newcastle, Oxford and Sussex) were involved in delivering the trial, which took five years to complete.
Publication details
Trauma-focused therapy integrated with cognitive behavioural therapy for psychosis for people with post-traumatic stress disorder and psychosis (the STAR trial):a multicentre, pragmatic, randomised trial in the UK', The Lancet Psychiatry (2026). DOI: 10.1016/S2215-0366(26)00090-8
Journal information: The Lancet Psychiatry
Key medical concepts
Psychotic DisordersPost-Traumatic Stress Disorder
Clinical categories
PsychiatryPsychology & Mental health Provided by King's College London Who's behind this story?
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