‘Finding Solid Ground’ in inpatient treatment for dissociative disorder patients followed by transition to outpatient treatment settings: a one-year follow-up pilot study

ABSTRACT

Background: Effective treatments for patients with complex dissociative disorders (CDDs) are urgently needed. The psychoeducational programme Finding Solid Ground (FSG) has been shown to be effective as an adjunct to individual outpatient therapy.

Objective: This naturalistic pilot study evaluates changes in adaptive capacities and symptoms in adults with CDDs during a 1 year follow-up period, including a 3 month inpatient FSG-based treatment followed by patients’ continuation of the FSG programme in their outpatient treatment setting.

Method: Thirty adult patients with CDDs were included in the study. Patients were admitted in four consecutive groups to the inpatient FSG-based programme, combining group and individual therapy. FSG has 30 topics, each consisting of a short educational video, a psychoeducational script, and written and practical exercises. Patients completed eight topics during the inpatient stay and continued with the remaining topics during their 9 month outpatient period. Changes in adaptive capacities and symptoms were explored, using mixed-model analysis and calculating reliable change.

Results: Patients completed on average 19 of the 30 topics during the 1 year study period. They improved with large effect sizes on adaptive capacities, post-traumatic stress disorder (PTSD) symptoms, and self-compassion; a moderate effect size on difficulties in emotion regulation; and a small effect size on dissociation. The majority reliably improved on adaptive capacities, PTSD symptoms, difficulties in emotion regulation, and self-compassion; while almost one-third reliably improved on dissociation. Deterioration rates were small. The highest improvement rates were observed in patients who had completed the highest number of FSG topics.

Conclusions: This naturalistic pilot study shows the feasibility of the FSG programme in an inpatient treatment context, followed by patients’ continuation of the programme in their local treatment setting. The results also suggest that progress with FSG topics is associated with better outcomes. Further studies are needed to replicate the findings.

HIGHLIGHTS

• This 1-year naturalistic pilot explored adaptive capacities and symptoms in 30 patients with dissociative disorder using the psychoeductional programme, Finding Solid Ground. in a context involving inpatient and outpatient treatment.

• Most patients showed clinically meaningful improvements in adaptive capacities and symptoms.

• Findings suggest that progress on the programme is associated with better outcomes, underlining the importance of strengthening interactions between actors at different levels of health services for patients with prolonged treatmen needs.

1. Introduction

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) presents five categories of dissociative disorders (DDs) [American Psychiatric Association (APA), 2022]. The most severe DDs, dissociative identity disorder (DID) and other specified dissociative disorder, subtype 1 (OSDD-1), are often presented together and referred to as complex dissociative disorders (CDDs) (Mueller-Pfeiffer et al., 2012) because of similarities in dissociative organization of the personality, i.e. identity fragmentation and/or amnesia. CDDs and other conditions with prominent levels of dissociation are associated with childhood trauma, high levels of mental and physical symptoms, extensive comorbidity, impaired functioning, and high financial costs to society (Langeland et al., 2020). The problems include severe levels of post-traumatic stress symptoms, difficulties with emotion regulation, self-compassion, and relationships, and suicidality and self-destructive behaviour (Brand et al., 2022).

Although recommendations for the assessment and treatment of CDDs are available [International Society for the Study of Trauma and Dissociation (ISSTD), 2011], treatment trajectories of CDDs are often time-consuming and face many obstacles, including failure to recognize and diagnose CDDs and attrition from treatment, leading to chronic conditions of disability and impairment (Brand, 2023). Furthermore, barriers to accessing and continuing mental health treatment are highly frequent among traumatized individuals, including disruptions in the therapeutic relationship and alliance, and a lack of trained providers (Nester et al., 2022).

Uncontrolled longitudinal treatment studies have indicated that CDD patients improve with time when treated in line with the ISSTD recommendations (Brand et al., 2009, 2013, 2019; Jepsen, Langeland, et al., 2014; Myrick et al., 2017). Reduced costs following dissociation-focused treatment have also been reported (Langeland et al., 2020). However, the first randomized controlled trial (RCT) on CDDs (Bækkelund et al., 2022) showed no improvement in post-traumatic stress, dissociative and general psychiatric symptoms, or interpersonal functioning following a 20 week group psychoeducational trauma and dissociation informed programme, which was based on 20 topics from the manual Coping with trauma-related dissociation by Boon et al. (2011). The authors suggested that the lack of symptom improvement was due to patients’ need for a better balance between exposure and coping based on the patient’s capacity. This suggestion was supported by the results of a qualitative study based on data collected 6 months after the group treatment had finished (Holbæk et al., 2024).

In another qualitative study, Pierorazio et al. (2025) reported that a paced treatment approach and psychoeducation were helpful when examining patients’ experiences using a new psychoeducational programme (Brand et al., 2025). This web-delivered psychoeducational and present-centred stabilization programme, ‘Finding Solid Ground’ (FSG) (Brand et al., 2022), was designed for patients with CDDs and other conditions with severe levels of dissociation. The FSG programme does not include trauma memory processing but focuses on psychoeducation and building skills in a paced manner to address the main problems presented by patients with DDs and trauma-related disorders, i.e. dissociation, emotion regulation difficulties, post-traumatic stress disorder (PTSD) symptoms, unhealthy/unsafe coping strategies, and trauma-based thoughts. Interim results from an ongoing RCT, which compares FSG provided as an adjunct to individual therapy for outpatients with CDDs and other conditions with severe levels of dissociation to a waiting-list control condition, demonstrated improvement after 12 months of adaptive capacities (such as healthy managing dissociation-related symptoms), PTSD symptoms, emotion regulation, and self-compassion (Brand et al., 2025). Dissociation also improved, but it could not be attributed to FSG. Importantly, these are only preliminary results, and no conclusion can yet be reached on whether FSG had an additional effect on treatment. The authors noted that dissociation also declined in the waiting-list group, possibly because therapists, mainly recruited through professional networks focused on the treatment of trauma-related dissociation, may have already been working on grounding as well as fostering co-operation among self-states, which decreases dissociative symptoms (Brand et al., 2025, p. 9). These findings support the effectiveness of FSG; however, the effects of FSG in other treatment contexts and in groups consisting solely of patients diagnosed with the most severe forms of dissociation, CDD, remain to be examined.

1.1. Treatment context

Modum Bad Psychiatric Clinic in Norway has offered a 3 month inpatient treatment programme for adults with complex PTSD and DDs related to childhood maltreatment for over 20 years. Over the years, we have faced two major challenges in the treatment of CDDs. The first is how to provide more effective inpatient treatment to this patient group. Previous studies (Jepsen, Langeland, et al., 2014; Jepsen, Langeland, & Heir, 2014) found that patients with CDDs or high in dissociation had higher levels of distress, poorer outcome, and lower effect sizes following 3 months of inpatient treatment compared to complex PTSD patients low in dissociation. The second challenge is how to ensure continuity in patients’ treatment following their discharge and transition to outpatient treatment settings.

Although many patients report at follow-up that they have received helpful outpatient treatment after discharge, several report severe obstacles to their recovery process. These are related to disruptions in treatment, loss of and shifts in therapeutic relationships, lack of a trauma- and/or dissociation-informed therapy, and not feeling understood and helped adequately. Many patients also report that the 3 months of inpatient treatment had been too short for them to consolidate the improvements and skills that they acquired.

In line with these patients’ experiences, the Norwegian health authorities recently recognized the importance of strengthening the interaction between actors at different levels of health services for patients with prolonged treatment needs (Det kongelige helse- og omsorgsdepartementet, 2024). The need for a consistent treatment approach across time and treatment providers for patients with CDDs led to the development of a new treatment framework where FSG was started in our residential setting and continued after discharge in collaboration with local treatment providers.

1.2. Study aims and hypotheses

The present prospective 1 year pilot study aimed to explore the feasibility of FSG for DD patients in a naturalistic setting, involving patients’ transition from one treatment level to another. Despite the well-known limitations of naturalistic studies compared to RCTs, their strengths include flexibility and the provision of information that mirrors the reality of clinical settings, including how an intervention works in the field. As such, the current study complements RCT findings on FSG effects, where FSG served as an adjunct to ongoing individual outpatient therapy in established therapeutic relationships (Brand et al., 2025). Furthermore, treatment involved a transition from inpatient (3 months) to outpatient care (9 months). Thus, we examine whether FSG could serve as a consistent framework across treatment levels, as commonly called for by patients with CDDs.

The first research question was whether CDD patients improve in adaptive capacities (i.e. safe management of trauma- and dissociation-related challenges) and symptoms following work with FSG in both treatment settings. We hypothesized that patients would improve in adaptive capacities, emotion regulation, PTSD symptoms, self-compassion, and dissociation following their participation in FSG during the 1 year study period. The second research question was whether progress in work with FSG was associated with changes in adaptive capacities and symptoms. We hypothesized that after the 1 year study period, the rate of reliable improvement would be higher in patients who had completed more FSG topics than in patients who had completed fewer FSG topics on all outcome measures.

2. Method

2.1. Participants and procedure

Participants were recruited from referrals to a national clinic in Norway providing psychotherapy in a residential setting for adult patients with psychiatric disorders related to childhood trauma. Patients are referred to this clinic when local treatment is insufficient. The patients have usually been experienced distress and functional impairment for many years and have received various treatments before, although not necessarily any trauma-informed treatment. Referred individuals were invited to a 12 day evaluation stay in groups of eight people at the clinic to assess their eligibility for the 3 month dissociation-focused treatment programme. Inclusion criteria to the programme are (1) age 18–65 years; (2) exposure to childhood trauma; and (3) DD. Exclusion criteria are psychosis, severe ongoing self-destructive behaviour, severe somatic illness, current life crisis (e.g. loss or divorce, ongoing stressful court case), and severely disturbed group functioning.

Childhood trauma was measured with the Childhood Trauma Questionnaire (CTQ) (Bernstein et al., 2003). Dissociative disorders were assessed with the Structured Clinical Interview for DSM-IV Dissociative Disorders – Revised (SCID-D-R) (Steinberg et al., 2000) or SCID-D (Steinberg, 2023). Other Axis I diagnoses were assessed using the Mini-International Neuropsychiatric Interview (MINI) (Sheehan et al., 1998). In addition, patients’ group functioning, current life crises, and stressors were evaluated by clinical interviews and observations, and somatic illness was evaluated by a medical doctor during the pretreatment evaluation stay.

Study participants were derived from four patient groups of eight individuals (N = 32) admitted consecutively from June 2023 to September 2024 to the 3 month inpatient treatment. Two of the 32 patients were excluded; one did not give consent to participate and the other had received additional treatment conflicting with treatment adherence to the FSG focus during the residential stay. Although one patient did not receive a DD diagnosis, a score (> 30) on the Dissociation Experiences Scale (Carlson & Putnam, 1993) indicating a high level of dissociation was reported. See Table 1 for demographic and clinical characteristics of the patients.

Table 1.

Patient demographics and characteristics upon admission to residential treatment (N = 30).

Variable	n (%)	M (SD) (range)
Age (years)		43.50 (10.81) (24–61)
Gender
Female	28 (93.3)
Male	2 (6.7)
Marital status
Married/cohabiting	15 (50.0)
Divorced	8 (26.7)
Not married	7 (23.3)
Living situation
Alone	12 (40.0)
Not alone	18 (60.0)
Highest completed education
University, master’s	5 (16.7)
College, bachelor’s	8 (26.7)
High school (10–12 years)	10 (33.3)
Elementary school (1–9 years)	6 (20.0)
Other	1 (3.3)
Primary source of income
Employed	5 (16.7)
Rehabilitation/sick leave	8 (26.7)
Disability pension	16 (53.3)
Other	1 (3.3)
Age at first contact with mental health services (years)a		22.63 (10.02) (8–50)
Years of active treatmentb		12.00 (6.75) (3–34)
History of inpatient treatmenta	24 (88.9)
Had other diagnoses before a DDc	24 (92.3)
	) (
Self-reported number of diagnoses before a DDb		2.39 (1.88) (0–7)
Self-reported diagnoses before a DDb
Eating disorder	3 (13.0)
Depressive or bipolar disorder	13 (56.5)
Anxiety or PTSD	7 (30.4)
Complex PTSD	12 (52.2)
ADHD	2 (8.7)
Neurasthaenia, fatigue, or fibromyalgia	2 (8.7)
Personality disorder	8 (34.8)
ICD-10 DD
F44.81 DID	3 (10.0)
F44.88 Other specified DD	19 (63.4)
F44.7 Mixed DD	1 (3.3)
F44.9 Unspecified DD	6 (20.0)
No DD diagnosis	1 (3.3)
	) (
PTSD	30 (100)
Number of current Axis I disorders, excluding PTSD and DD		1.80 (1.40) (0–6)
Number of medications for psychological symptoms		3.03 (1.47) (1–6)
Number of medications for somatic symptoms/illnesses		5.00 (5.64) (0–27)
Medication, any	30 (100)
Antidepressants	10 (33.3)
Anxiolytics	5 (16.7)
Hypnotics	11 (36.7)
Analgesics	26 (86.7)
Mood stabilizers	1 (3.3)
Stimulants (ADHD medication)	1 (3.3)
Antipsychotics	13 (43.3)
Childhood Trauma Questionnaired		91.25 (22.23) (52–133)
Emotional abuse		21.80 (3.80) (13–25)
Physical abuse		13.25 (6.47) (5–25)
Sexual abuse		15.72 (7.54) (5–25)
Emotional neglect		15.95 (7.44) (5–25)
Physical neglect		14.90 (3.54) (8–22)

Note: DD = dissociative disorder; PTSD = post-traumatic stress disorder; ADHD = attention deficit hyperactivity disorder; ICD-10 = International Classification of Diseases, 10th revision; DID = dissociative identity disorder.

^an = 27; ^bn = 23; ^cn = 26; ^dn = 28.

In line with the Norwegian Health Research Act of 2008 (Helse- og omsorgsdepartementet, 2010), the study was approved by the hospital’s ethical review board (Personvernombud). The participants provided informed consent before entering the study. In addition, at discharge from the inpatient treatment, all patients and their local treatment providers confirmed and provided consent to continue with the FSG programme during the outpatient period.

Self-reported outcome measures were administered at three time-points: upon admission to inpatient treatment (T1), at discharge from inpatient treatment and transition to outpatient treatment (T2), and at follow-up 1 year after admission to the inpatient period (T3). The total number of completed FSG topics was recorded at follow-up (T3).

2.2. Treatment

2.2.1. Inpatient period

A multidisciplinary treatment team consisting of three individual therapists (two psychologists and a psychiatrist) and three or four milieu therapists (psychiatric nurses, social worker) provided the individual and group sessions. All therapists possessed basic knowledge about the treatment of complex trauma and dissociation, as well as clinical experience. The Finding Solid Ground workbook (Schielke et al., 2022) was used as a treatment manual. Before the start of the study, the team attended a 48 h online course with the authors of FSG. Furthermore, the treatment team received online group supervision every second week from the FSG workbook’s first author (HS). In addition, the week’s topic was discussed on a daily basis in team meetings. The therapists were offered individual supervision by specialists with experience in working with DDs and the FSG programme, upon request. New team members also received training and supervision (see Supplemental Material I).

The implementation of FSG into the 3 month inpatient group-based programme included the use of Norwegian translations of the psychoeducational videos used in the RCT (Brand et al., 2025) and texts from the FSG workbook (Schielke et al., 2022). The multidisciplinary team provided a daily FSG group session (60 min) and three weekly individual sessions. After an introductory week, with access to three videos with introductory information about FSG, patients progressed with one FSG topic per week. During the inpatient period, eight FSG topics, each including a video lasting for approximately 8 min with psychoeducation about the focus of the topic, a script of the video text, and both written and practice exercises, were completed. The weekly schedule offered a daily FSG group in this order: (1) a psychoeducational group with presentation of the week’s topic and material; (2) a group for working individually with the exercises; (3) horse-assisted therapy using non-verbal skills training; (4) a reflection group for patients to share and discuss their experiences; and (5) a group for exercising the skills and preparing for the weekend. Furthermore, patients weekly joined a ward meeting and two groups for physical activities.

2.2.2. Outpatient period

The outpatient therapists were all authorized psychiatric healthcare providers: psychologists, psychiatrists, psychiatric nurses, or social workers. One week before patients’ transition to the local setting, the outpatient therapists were offered an online group meeting with the teams’ specialist to transfer information on the FSG programme. A progress plan, suggesting a rate of progress of about two topics every 3 weeks in the 9 month outpatient period, was shared, to ensure that there was adequate time to make meaningful use of each topic as well as to complete all remaining FSG topics. The outpatient therapist provided the patient with the week’s password needed to access the next topic’s video and text. If a therapist ended treatment and another treatment provider took over, the new treatment provider was informed about the conditions for using the FSG material.

2.3. Measurement

Adaptive capacities were measured using the Progress in Treatment Questionnaire – Patient Version (PITQ-p) (Schielke et al., 2017), which measures how often adaptive capacities, e.g. a person’s ability to safely manage emotions, unsafe impulses, trauma- and dissociation-related symptoms, and relationships, were used in the past week. The PITQ-p has 32 items, scored on an 11-point scale ranging from 0% (‘never true’) to 100% (‘always true’). Items 27–32 on dissociative self-states are completed ‘if applicable’. As only 21 of 30 participants had completed these items, statistical calculations were performed for items 1–26, consistent with the approach used by Brand et al. (2025). Items were averaged; higher scores indicate greater adaptive capacities. The PITQ-p showed good internal consistency, test–retest reliability, and convergent validity (Schielke et al., 2017). In the current study, internal consistency was 0.93 at T1, 0.93 at T2, and 0.96 at T3.

PTSD symptoms were measured with the PTSD Checklist for DSM-5 (PCL-5) (Weathers et al., 2013). The PCL-5 has 20 items, with a five-point scale ranging from 0 (‘not at all’) to 4 (‘extremely’) to assess PTSD symptoms over the past month. The potential range of total sum scores is 0–80, with higher scores indicating greater PTSD symptom severity. The PCL-5 has strong internal consistency, test–retest reliability, convergent validity, and discriminant validity (Blevins et al., 2015). In the present study, Cronbach’s α was 0.92 at T1, 0.92 at T2, and 0.93 at T3.

Self-compassion was measured with the Self-Compassion Scale – Short Form (SCS-SF) (Raes et al., 2011). The SCS-SF has 12 items with a five-point scale ranging from 1 (‘almost never’) to 5 (‘almost always’). Total average scores were calculated after reverse scoring of relevant items, with higher scores indicating greater self-compassion. The SCS-SF shows good internal consistency and convergent validity with its long form (Raes et al., 2011). In the current study, the internal consistency was 0.81 at T1, 0.88 at T2, and 0.90 at T3.

Emotion dysregulation was measured with the Difficulties in Emotion Regulation Scale (DERS) (Gratz & Roemer, 2004). The DERS has 36 items, with a five-point scale ranging from 1 (‘almost never’; 0–10% of the time) to 5 (‘almost always’; 91–100%) over the past month. The potential range of total sum scores is 36–100, with higher scores indicating higher emotion dysregulation. The scale has good test–retest reliability, construct validity, and predictive validity (Gratz & Roemer, 2004). In the current study, internal consistency across time was 0.96 at T1, 0.95 at T2, and 0.94 at T3.

Dissociation was measured with the Dissociative Experiences Scale-II (DES-II) (Carlson & Putnam, 1993). The DES has 28 items, with an 11-point scale ranging from 0% (‘never’) to 100% (‘always’). The potential range of total average scores is 0–100, with higher scores showing higher dissociation. The DES-II has good internal reliability, test–retest reliability, and construct validity (Carlson & Putnam, 1993). In the current study, internal consistency across time was 0.96 at T1, 0.97 at T2, and 0.97 at T3.

2.4. Adherence to the programme

During the inpatient period, loyalty to the FSG programme was discussed weekly using the document ‘FSG Group Fidelity Questions’ (see Supplemental Material II). Therapists administered a self-report checklist of ‘Therapeutic Activities, revised’ as a self-check of their therapeutic activities during every individual session (see Supplemental Material IIIA and B). To ensure that the first phase FSG-stabilization work had not interfered with the second phase trauma-processing work, a question was added in the measurement of therapeutic activities. Owing to the naturalistic study design, no information was collected on the outpatient therapists’ adherence to the programme.

2.5. Statistical analysis

Data analysis was performed using SPSS version 29.0.0.0. All patients except one came back for the follow-up assessment. Furthermore, there were some missing data in patients’ self-reports that were not due to non-attendance. To provide transparency on missing data, the numbers (n) of the specific measurement and time-point are reported in the tables. Descriptive statistics included means and standard deviations as well as frequencies. Linear mixed-effects models were used to examine overall changes from pretreatment to follow-up, as well as changes in the two treatment periods separately (i.e. the inpatient and the outpatient period). The dependent variables were emotion dysregulation (DERS), PTSD symptoms (PCL-5), dissociation (DES-II), adaptive capacities (PITQ-p), and self-compassion (SCS-SF). A random intercept was included to account for baseline individual differences in the outcome variables.

Reliable changes in the inpatient period (T1 to T2), the outpatient period (T2 to T3), and the 1 year study period (T1 to T3) were assessed by a change in observed symptom scores that exceeded a threshold defined by chance variation and the reliability of each test (Christensen & Mendoza, 1986). This was calculated as 1.96 × SD [pre-test] × sqr2(1 − reliability), and yielded the following minimum reliable change scores: PITQ: 12.42; PCL-5: 6.67; SCS-SF: 0.64; DERS: 15.94; and DES-II: 15.00. Since the scores on the PCL-5 and DERS are reported as whole numbers, the reliable change scores were rounded conservatively to 7 and 16, respectively. To examine reliable change in relation to progress in the FSG work, three subgroups were defined based on the number of FSG topics completed during the outpatient period. The first eight topics could be completed during the inpatient period, leaving 22 topics to be completed. Dividing these 22 topics into three equal subgroups provided the basis for the following categories for the subgroup analyses: Subgroup 1: 8–15 topics; Subgroup 2: 16–22 topics; and Subgroup 3: 23–30 topics.

The statistical significance was set at two-tailed p < .05, and effect sizes, using Cohen’s d, for changes in symptom scores and adaptive capacities were calculated from T1 to T2, from T2 to T3, and from T1 to T3, where coefficients of 0.2, 0.5, and 0.8 indicate minimum values for small, medium, and large effects, respectively (Cohen, 1988).

3. Results

All patients reported multiple forms of early relational trauma. All CTQ subscales, except for emotional neglect (moderate), were in the severe range. Table 2 presents the mean scores and standard deviations of the outcomes at T1, T2, and T3; effect sizes (Cohen’s d) during the T1–T2, T2–T3, and T1–T3 periods; and linear change from T1 to T2, T2 to T3, and T1 to T3, respectively. Regarding dimensional changes, adaptive capacities and all symptoms improved from pretreatment to follow-up (T1–T3), with large effect sizes on self-compassion, adaptive capacities, and PTSD symptoms, a moderate effect size on difficulties in emotion regulation, and a small effect size on dissociation. During the inpatient period, adaptive capacities and PTSD symptoms showed significant improvements, while difficulties in emotion regulation, self-compassion, and dissociation did not. During the outpatient period, all symptoms improved, while adaptive capacities did not improve any further.

Table 2.

Means, effect sizes, and mixed linear models with fixed effects of time.

	Mean (SD)						Cohen’s d effect sizes			Mixed piecewise linear models				Mixed linear models
Measure	T1		T2		T3		T1–T2	T2–T3	T1–T3	T1–T2	p	T2–T3	p	T1–T3	p
PITQ-p	n = 30	45.19 (13.62)	n = 30	57.67 (15.86)	n = 29	59.33 (19.56)	0.84	0.09	0.84	12.476	< .001	2.249	.270	6.568	< .001
PCL-5	n = 28	52.66 (12.23)	n = 28	46.60 (15.60)	n = 25	41.32 (13.99)	0.43	0.36	0.86	−6.008	.006	−4.713	.033	−5.369	< .001
SCS-SF	n = 30	2.06 (0.62)	n = 29	2.21 (0.73)	n = 25	2.69 (0.77)	0.22	0.64	0.90	0.165	.214	0.520	.003	0.322	< .001
DERS	n = 30	123.42 (27.17)	n = 29	120.45 (24.83)	n = 25	104.35 (26.51)	0.11	0.63	0.71	−3.068	.402	−16.055	< .001	−8.689	< .001
DES-II	n = 28	44.90 (20.35)	n = 28	42.07 (22.35)	n = 25	35.63 (21.83)	0.13	0.29	0.44	−0.527	.790	−6.736	.028	−2.834	.026

Note: PITQ-p = Progress in Treatment Questionnaire – Patient Version; PCL-5 = PTSD Checklist for DSM-5; SCS-SF = Self-Compassion Scale – Short Form; DERS = Difficulties in Emotion Regulation Scale; DES-II = Dissociation Experiences Scale-II; T1 = admission to inpatient treatment; T2 = discharge from inpatient treatment; T3 = follow-up.

Table 3 shows the percentages of participants who reliably improved, deteriorated, or remained unchanged. During the 1 year study period, the majority improved on adaptive capacities, PTSD symptoms, emotion regulation, and self-compassion, and almost one-third of the sample improved reliably on dissociation. Deterioration rates were less than 5% in the study period.

Table 3.

Frequency (%) of reliable changes (RCI) in three different outcome categories for the PITQ-p, PCL-5, SCS-SF, DERS, and DES-II for the study sample during the inpatient period (T1–T2), outpatient period (T2–T3), and 1 year study period (T1–T3).

	Improved			Unchanged			Deteriorated
Measure	T1–T2 N (%)	T2–T3 N (%)	T1–T3 N (%)	T1–T2 N (%)	T2–T3 N (%)	T1–T3 N (%)	T1–T2 N (%)	T2–T3 N (%)	T1–T3 N (%)
PITQ-p (items 1–26) T1–T2: n = 30; T2–T3: n = 29; T1–T3: n = 29	15 (50.0)	5 (17.2)	16 (55.2)	15 (50.0)	21 (72.4)	12 (41.4)	0 (0.0)	3 (10.3)	1 (3.4)
PCL-5 T1–T2: n = 27; T2–T3: n = 25; T1–T3: n = 24	14 (51.9)	10 (40.0)	13 (54.2)	9 (33.3)	12 (48.0)	10 (41.7)	4 (14.8)	3 (12.0)	1 (4.2)
SCS-SF T1–T2: n = 29; T2–T3: n = 24; T1–T3: n = 25	6 (20.7)	8 (33.3)	14 (56.0)	18 (62.1)	16 (66.7)	10 (40.0)	5 (17.2)	0 (0.0)	1 (4.0)
DERS T1–T2: n = 29; T2–T3: n = 25; T1–T3: n = 25	7 (24.1)	12 (48.0)	15 (60.0)	16 (55.2)	12 (48.0)	9 (36.0)	6 (20.7)	1 (4.0)	1 (4.0)
DES-II T1–T2: n = 27; T2–T3: n = 25; T1–T3: n = 24	1 (3.7)	5 (20.0)	7 (29.2)	24 (88.9)	19 (76.0)	16 (66.7)	2 (7.4)	1 (4.0)	1 (4.2)

Note: PITQ-p = Progress in Treatment Questionnaire – Patient Version; PCL-5 = PTSD Checklist for DSM-5; SCS-SF = Self-Compassion Scale – Short Form; DERS = Difficulties in Emotion Regulation Scale; DES-II = Dissociation Experiences Scale-II; T1 = admission to inpatient treatment; T2 = discharge from inpatient treatment; T3 = follow-up.

Reliable change index (RCI) cut-off: PITQ = 12.42; PCL-5: 7; SCS-SF = 0.64; DERS = 16; DES-II = 15.00.

The mean number of FSG topics completed at follow-up was 19.61 (SD = 8.19; range 6–30). Table 4 presents the reliable change rates and Table 5 presents the mean reliable change rates in adaptive capacities and symptoms in the three study periods for the three subgroups, based on the number of FSG topics completed at follow-up. One patient had only completed six topics at discharge from the inpatient stay. This patient was included in Subgroup 1. This resulted in the following distribution-based number of completed topics subgroups: Subgroup 1 had completed ≤ 15 topics, Subgroup 2 had completed 16–22 topics, and Subgroup 3 had completed 23–30 topics at follow-up. Because of the modest sample size, the number of observations per cell is low and no tests of potential significant differences among the three subgroups could be conducted. Finally, the inpatient therapists provided the FSG interventions with sufficient adherence to meet the needs of each patient (see Supplementary Material IIIC and D).

Table 4.

Reliable improvement (RCI) and deterioration rates in three different outcome categories for the PITQ-p, PCL-5, SCS-SF, DERS, and DES-II in the inpatient period (T1–T2), outpatient period (T2–T3), and 1 year study period (T1–T3) for subgroups organized according to the number of FSG topics completed at follow-up (N = 28).

	T1–T2		T2–T3		T1–T3
	Inpatient		Outpatient		Inpatient and outpatient
	(3 months)		(9 months)		(1 year)
Measure	Improved N (%)	Deteriorated N (%)	Improved N (%)	Deteriorated N (%)	Improved N (%)	Deteriorated N (%)
PITQ-p
Subgroup 1a T1–T2: n = 9; T2–T3: n = 9; T1–T3: n = 9	4 (44.4)	0 (0.0)	0 (0.0)	2 (22.2)	3 (33.3)	1 (11.1)
Subgroup 2a T1–T2: n = 10; T2–T3: n = 10; T1–T3: n = 10	6 (60.0)	0 (0.0)	2 (20.0)	1 (10.0)	7 (70.0)	0 (0.0)
Subgroup 3a T1–T2: n = 9; T2–T3: n = 9; T1–T3: n = 9	4 (44.4)	0 (0.0)	3 (33.3)	0 (0.0)	6 (66.7)	0 (0.0)
PCL-5
Subgroup 1 T1–T2: n = 9; T2–T3: n = 6; T1–T3: n = 6	6 (66.7)	0 (0.0)	0 (0.0)	1 (16.7)	4 (66.7)	0 (0.0)
Subgroup 2 T1–T2: n = 9; T2–T3: n = 10; T1–T3: n = 9	3 (33.3)	3 (33.3)	5 (50.0)	2 (20.0)	2 (22.2)	1 (11.1)
Subgroup 3 T1–T2: n = 9; T2–T3: n = 9; T1–T3: n = 9	5 (55.6)	1 (11.1)	5 (55.6)	0 (0.0)	7 (77.8)	0 (0.0)
SCS-SF
Subgroup 1 T1–T2: n = 8; T2–T3: n = 5; T1–T3: n = 6	1 (12.5)	1 (12.5)	1 (20.0)	0 (0.0)	3 (50.0)	0 (0.0)
Subgroup 2 T1–T2: n = 10; T2–T3: n = 10; T1–T3: n = 10	2 (20.0)	2 (20.0)	2 (20.0)	0 (0.0)	4 (40.0)	1 (10.0)

Note: PITQ-p = Progress in Treatment Questionnaire – Patient Version; PCL-5 = PTSD Checklist for DSM-5; SCS-SF = Self-Compassion Scale – Short Form; DERS = Difficulties in Emotion Regulation Scale; DES-II = Dissociation Experiences Scale-II; FSG = Finding Solid Ground; T1 = admission to inpatient treatment; T2 = discharge from inpatient treatment; T3 = follow-up.

^aSubgroups based on number of FSG topics completed at follow-up: Subgroup 1: ≤ 15 topics; Subgroup 2: 16-22 topics; Subgroup 3: 23–30 topics. Reliable change index (RCI) cut-off: PITQ = 12.42; PCL-5: 7; SCS-SF = 0.64; DERS = 16; DES-II = 15.00.

Table 5.

Mean improvement and deterioration rates (range) of the outcome measurements (PITQ-P, PCL-5, SCS-SF, DERS, and DES-II) in the inpatient period (T1–T2), outpatient period (T2–T3), and 1 year study period (T1–T3) for subgroups organized according to the number of FSG topics completed at follow-up (N = 28).

Subgroupa	Number of FSG topics completed at follow-up	T1–T2		T2–T3		T1–T3
		Inpatient		Outpatient		Inpatient and outpatient
		(3 months)		(9 months)		(1 year)
		Mean improvement rate (%) (range)	Mean deterioration rate (%) (range)	Mean improvement rate (%) (range)	Mean deterioration rate (%) (range)	Mean improvement rate (%) (range)	Mean deterioration rate (%) (range)
1	≤ 15; n = 9	36.9 (11.1–66.7)	4.72 (0.0–12.5)	10.68 (0.0–20.0)	11.1 (0–22.2)	43.3 (16.7–66.7)	2.2 (0–11.1)
2	16–22; n = 10	24.7 (0.0–60.0)	17.3 (0.0–33.3)	32.0 (10.0–60.0)	8.0 (0–20.0)	42.9 (22.2–70.0)	6.4 (0.0–11.1)
3	23–30; n = 9	26.7 (11.4–55.6)	15.5 (0–33.3)	46.6 (33.3–55.6)	0.0 (0.0–0.0)	66.7 (44.4–77.8)	2.2 (0.0–11.1)

Note: PITQ-p = Progress in Treatment Questionnaire – Patient Version; PCL-5 = PTSD Checklist for DSM-5; SCS-SF = Self-Compassion Scale – Short Form; DERS = Difficulties in Emotion Regulation Scale; DES-II = Dissociation Experiences Scale-II; FSG = Finding Solid Ground; T1 = admission to inpatient treatment; T2 = discharge from inpatient treatment; T3 = follow-up.

^aSubgroups based on number of FSG topics completed at follow-up: Subgroup 1: ≤ 15 topics; Subgroup 2: 16–22 topics; Subgroup 3: 23–30 topics.

4. Discussion

In this naturalistic pilot study, the feasibility of the psychoeducational programme Finding Solid Ground for patients with CDDs was examined during a 1 year period, including a 3 month inpatient treatment programme combining group and individual therapies based on FSG, followed by a 9 month outpatient period with patients’ individual continuation of FSG. In addition, patients attended a 5 day follow-up stay by the end of the outpatient period. No severe adverse events occurred.

The results supported the hypothesis that CDD patients with severe levels of childhood trauma would improve in adaptive capacities and symptoms following participation in FSG during the 1 year study period. The participants improved on adaptive capacities, PTSD and dissociative symptoms, emotion regulation skills, and self-compassion. For adaptive capacities, PTSD symptoms and self-compassion effect sizes were large, for emotion regulation difficulties moderate, and for dissociation small. More specifically, adaptive capacities improved significantly during the inpatient period, PTSD symptoms improved significantly during both the inpatient and outpatient periods, and emotion regulation difficulties, self-compassion, and dissociation improved significantly during the outpatient period. In addition, most patients reliably improved during the 1 year period on adaptive capacities, PTSD symptoms, emotion regulation skills, and self-compassion, and one-third improved reliably on dissociation. The reliable improvement rates were highest for adaptive capacities during the inpatient period, followed by PTSD symptoms, and highest for self-compassion, emotion regulation, and dissociation during the outpatient period. The order of FSG topics may account for differences observed in the various domains across inpatient versus outpatient treatment phases. FSG starts with building of grounding and containment skills for managing trauma-related symptoms. The significant improvements in adaptive capacities during the inpatient period may reflect improvement in patients’ practice and use of these specific skills as they are the major foci of the first eight FSG topics, completed during this treatment period. Self-compassion and regulation of emotions were specifically addressed in the topics after discharge from the inpatient treatment. In addition, the inpatient setting, which offered a combination of several group and individual therapy sessions, support from peers, and staff who are available day and night to support the patients in their work, may also have contributed to patients’ improvements in adaptive capacities (with a large effect size) during the 3 month inpatient stay compared to the absence of further improvement on this measure during the 9 month outpatient period. This could indicate that the inpatient treatment context is highly effective for building adaptive capacities compared to the outpatient setting. In the study by Brand et al. (2025), patients improved on adaptive capacities with moderate effect size after 6 months of individual therapy in an outpatient setting. Finally, the lack of improvement on emotion regulation and self-compassion during the inpatient period could be related to contextual differences, such as interpersonal challenging group dynamics, e.g. when patients compare themselves to others or become involved in conflicts. Thus, the relational matrix of the ward can temporarily act like a pressure cooker, intensifying emotional struggles and self-criticism before improvements are made.

Furthermore, few patients deteriorated across the measurements during the study period. These findings underline the importance of continuation of the treatment in collaboration with local treatment providers following discharge from the inpatient setting. These findings also support the relevance of the call from the health authorities (Det kongelige helse- og omsorgsdepartementet, 2024) to strengthen the interaction between actors at different levels of health services for patients with prolonged treatment needs.

Despite different treatment contexts, the patients’ improvements are in line with those of Brand et al. (2025), with similar effect sizes. Brand et al. (2025) investigated the effectiveness of FSG as an adjunct to ongoing psychotherapy in established therapeutic relationships for individuals with trauma-related dissociation, including patients with DID, the dissociative subtype of PTSD, and complex PTSD. The current study examined FSG administered to a patient sample predominantly diagnosed with CDD in a naturalistic setting, involving patients’ transference from one treatment level to another, with disruptions and shifts in therapeutic relationships. Nevertheless, most patients improved, which may indicate a robustness of the FSG programme. The findings suggest that patients with CDD may benefit from a stabilization-focused approach specifically designed for this patient group. Notably, the results from the current study on 30 CDD patients are superior to those of the 23 CDD patient subgroups included in a previous study in a similar treatment context (Jepsen, Langeland, et al., 2014), with higher improvement and lower deterioration rates for PTSD and dissociative symptoms. As Jepsen, Langeland, et al. (2014) did not specifically address dissociation, the current results may suggest that CDD patients benefit specifically from a programme that addresses dissociation and dissociation-related challenges. The improvement in dissociation (the ultimate treatment goal) came in the wake of improvements on the other FSG topics (building of healthy coping skills, including grounding and containment, emotion regulation, self-compassion, and PTSD symptoms), a finding that suggests that these must be dealt with first to reach this goal (Brand et al., 2025). Patients’ significant improvements from participating in FSG suggest that a structured and paced approach, focusing on psychoeducation, strengthening of adaptive capacities, and a balanced exposure to trauma-related responses, is beneficial for CDDs. The more paced approach may at least partly explain why the improvements shown by the current CDD patients after 1 year were superior to those of CDD patients in the RCT by Bækkelund et al. (2022). In contrast to the manual used by Bækkelund et al. (2022), FSG presents information in smaller bites, stressing the value of learning skills to manage dissociation and other trauma-related responses, and not providing extensive psychoeducation on dissociative parts and identities at a cognitive level that could be premature for some. The importance of prioritizing the acquisition of adaptive capacities early in the treatment of DD patients has been reported by patients participating in FSG programmes (Hawkins et al., 2026; Pierorazio et al., 2025).

In addition, despite the lack of formal significance tests, the hypothesis that a higher number of FSG topics completed at follow-up would be associated with better outcome received provisional support from the descriptive analyses. Improvement rates at follow-up across all measurements were highest among patients with most progress in the FSG work. Although it cannot be concluded that any decrease in symptoms is attributable to FSG participation and progression (e.g. highly motivated patients are likely to complete more topics and to benefit more from treatment in general), it may well be that the intense inpatient treatment put patients on track with how to work with the FSG programme, which they can continue in collaboration with their local treatment provider. The improvements in adaptive capacities and symptoms in the outpatient setting took place despite disruptions to the therapeutic framework and relationships (such as the loss of the peer group and availability of staff day and night) and variations in the therapists’ professional education. Thus, although the inpatient and the outpatient contexts offered different treatment conditions, the robust improvements during the 1 year study period among the patients with most progress in the FSG work suggest that the implementation of FSG in our treatment setting contributed towards solving some of the challenges faced in our treatment setting for DD patients: it is associated with improvements in adaptive capacities and symptoms, and patients can continue with the programme despite a transition to another treatment level. Furthermore, local therapists are offered a treatment guide for continuation of the treatment line provided. This indicates that for patients with CDDs, FSG can serve as a framework for a coherent treatment focus over time and across treatment levels, as called for by health authorities (Det kongelige helse- og omsorgsdepartementet, 2024).

4.1. Strengths and limitations

The study has some limitations, including the relatively small number of participants and the lack of a control group. It cannot be ruled out that the improvement in symptoms and adaptive capacities was due to natural recovery. Furthermore, the generalizability of the results is limited by the unit’s exclusion and inclusion criteria, such as the exclusion of patients with severe levels of comorbidity (e.g. active substance abuse) and behavioural problems (acute suicidality, severe self-injury). In addition, few men were included. The use of only self-report measures to assess treatment outcome raises concerns about possible response bias. In addition, the interpretation of results from an open pilot trial such as ours is complicated by a number of factors; for example, except for progress in FSG topics, no information was gathered on the content of the individual outpatient treatment, or adherence to the FSG manual by local therapists.

However, the naturalistic condition provides information about patients’ clinical trajectories in a real-life clinical setting involving their transition from one treatment setting to another, and it adds information about FSG in inpatient treatment. Although we cannot conclude that FSG caused the improvements, our findings support the feasibility of FSG in a naturalistic setting that mirrors the real-life clinical conditions experienced by many individuals with a CDD. The inclusion of data on individual reliable change, which also includes data on the association between progress in FSG work and change, is a strength.

4.2. Recommendations for clinical practice and research

Studies with stronger research designs are needed, e.g. a higher number of participants and comparison groups. Future studies could examine whether similar outcomes are observed in more diverse populations, including different age groups, gender, and treatment contexts. They could also compare the use of FSG in group versus individual therapy. Furthermore, it is relevant to examine whether therapists’ professional background and experience with trauma and dissociation, as well as training in how to work with FSG, are related to patients’ improvements.

5. Conclusion

Thirty patients with severe DDs improved with large effect sizes on adaptive capacities, PTSD symptoms, and self-compassion, moderate effect size on difficulties in emotion regulation, and small effect size on dissociation, following participation in FSG during a 3 month group-based inpatient treatment period followed by a 9 month individual outpatient period. In addition, reliable improvement rates were high and deterioration rates low after 1 year. Patients with the highest number of completed FSG topics at follow-up had the highest improvement rates, suggesting that FSG is helpful to inpatients with CDDs who continued FSG work in an outpatient setting. More studies with stronger research designs, such as trials including control or comparison groups, are needed to replicate our findings.

Funding Statement

The study was supported by Modum Bad Psychiatric Hospital. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability statement

Data not available due to ethical restrictions.

Supplemental Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/20008066.2026.2698899.