https://orcid.org/0009-0002-4684-6522
Figures
Abstract
Background
Sexual assault affects 35.6% of women globally. In Indonesia, 1 in 3 women aged 15–64 have experienced physical and/or sexual assault. This often leads to post-traumatic stress disorder (PTSD) and related symptoms. The standard PTSD treatments have cultural and resource limitations, which emphasize the need for a culturally adapted intervention. Somatic Experiencing® (SE)®, a body-oriented trauma therapy, has shown promise in reducing PTSD symptoms across diverse populations, but its cultural applicability and effectiveness in Indonesia remain under-investigated. This study addresses that gap by adapting SE®, for Indonesian women survivors of sexual assault.
Methods
This study is a parallel-group, randomized controlled trial (RCT) designed to assess the effectiveness of a 10-session group-based SE® intervention, compared withcontrol group. A total of 207 participants will be recruited and randomly assigned using a 2:1 allocation ratio (n = 138 intervention, n = 69 control). The intervention consists of structured group activities based on SE® principles, targeting improvements in PTSD symptoms, resilience, and quality of life. Furthermore, participants will be assessed at multiple points using standardized measures (PCL-5, CD-RISC-25, WHOQOL-BREF). Analysis will be conducted using SPSS version 22.0 for quantitative data and thematic coding for qualitative insights.
Discussion
This study represents the first RCT of culturally adapted SE® intervention in Indonesia. The findings are expected to inform trauma-focused clinical practice in low-resource settings and contribute to the global understanding of body-based therapy effectiveness in diverse cultural contexts. Results may also provide evidence for scalable group interventions targeting PTSD among women survivors of gender-based violence.
Citation: Ayudia L, Purba FD, Samuels A, Iskandarsyah A (2025) Study protocol for a randomized controlled trial of a group-adapted Somatic Experiencing® intervention for Indonesian women survivors of sexual assault with PTSD symptoms. PLoS One 20(12): e0336956. https://doi.org/10.1371/journal.pone.0336956
Editor: Fadwa Alhalaiqa, Qatar University College of Nursing, QATAR
Received: July 20, 2025; Accepted: October 28, 2025; Published: December 22, 2025
Copyright: © 2025 Ayudia et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data from this study will be made available upon study completion. Deidentified research data will be made publicly available through OSF when the study is completed and published. OSF registration link: https://osf.io/a8x7d Project DOI: https://doi.org/10.17605/OSF.IO/A8X7D.
Funding: This study is supported by Padjadjaran University Research Grant (No. 1549/UN6.3.1/PT.00/2023). The funding body has no role in study design, data collection, or reporting. There was no additional external funding received for this study.
Competing interests: The authors have declared that no competing interests exist.
List of Abbreviations:: ANS, Autonomic Nervous System; CBT, Cognitive Behavioural Therapy; CD-RISC-25, Connor-Davidson Resilience Scale (25-item version); CONSORT, Consolidated Standards of Reporting Trials; DSM-5, Diagnostic and Statistical Manual of Mental Disorders, 5th Edition; HAT, Helpful Aspects of Therapy; ITT, Intention-to-Treat; NGO, Non-Governmental Organization; PCL-5, PTSD Checklist for DSM-5; PPA, Pusat Pelayanan Terpadu (Integrated Service Center); PTSD, Post-Traumatic Stress Disorder; RCT, Randomized Controlled Trial; SCID, Structured Clinical Interview for DSM Disorders; SE, Somatic Experiencing®; SIBAM, Sensation, Image, Behaviour, Affect, Meaning; SRS, Session Rating Scale; TAU, Treatment as Usual; WHOQOL-BREF, WHO Quality of Life–Brief
Introduction
Sexual assault affects 35.6% of women globally. In Indonesia, 1 in 3 women aged 15-64 have reported having experienced physical and/or sexual assault during their lifetime, either by a partner or a non partner [1]. A 2016 online survey by Lentera Sintas Indonesia showed that 46.7% of 25,213 participants had experienced some form of sexual assault [2]. Additionally, Komnas Perempuan (2021) recorded 955 cases of sexual assault in public and neighborhood spaces during 2020 [3].
Sexual assault refers to any attempt to obtain sexual acts through coercion or force, such as rape by an intimate partner or strangers. Epidemiological studies have shown that sexual assault is the trauma with the highest risk of resulting in post-traumatic stress disorder (PTSD) [4]. Neurobiologically, PTSD often emerges from dysregulation of autonomic responses from incomplete or overwhelmed defensive reactions to trauma. These can manifest as hyperarousal (e.g., panic, hypervigilance), hypoarousal (numbness, fatigue), or dissociative states (e.g., detachment, disconnection). During traumatic events, the autonomic nervous system (ANS) may enter an emergency alarm state, characterized by activation of sympathetic fight-or-flight responses or parasympathetic shutdown (freeze or collapse), depending on the individual’s neurobiological and contextual factors. When these defensive responses remain incomplete such as an urge to run or resist that is never carried out, they may become ‘‘stuck’’ in the body, contributing to chronic stress and PTSD symptoms [5,6]. It is important to note that not all survivors respond in the same way; dissociation, emotional numbing, and immobilization may occur with or without classical ‘‘freeze’’ responses. Although this response may provide temporary protection, it causes unexpressed energy to accumulate in the body. Over time, this unresolved activation disrupts the hypothalamic-pituitary-adrenal (HPA) axis, leading to demoralization, interpersonal dysfunction, stigma, and diminished self-regulation capacity [7,8].
Despite growing access to legal and psychological support, many women with trauma histories face barriers to care, including cost, stigma, lack of trauma-informed providers, and low treatment retention [9]. Although evidence-based treatments such as eye movement desensitization and reprocessing (EMDR), Cognitive Behavioral Therapy (CBT), and Prolonged Exposure (PE) have shown efficacy in reducing PTSD symptoms [10], dropout rates can reach 18%, largely due to difficulties tolerating trauma exposure and autonomic dysregulation [11–13].
Top-down approaches often depend heavily on verbal expression, memory, and cognitive processing. These demands can exceed the capacities of individuals facing trauma-related impairment in language, attention, and executive function, particularly in low-resource contexts like Indonesia, where access to mental health care is scarce, limited cognitive capacity, and executive functioning limitations may impede engagement in cognitively demanding treatment [3,14]. These limitations highlight the need for bottom-up approaches. Recent neurobiological models, such as the Polyvagal Theory emphasizes the importance of addressing a wide spectrum of autonomic responses in trauma, supporting methods that directly target interoceptive and proprioceptive processes to regulate the nervous system and restore safety [15].
Somatic Experiencing® is a biopsychological model developed by Levine (1998). The term ‘‘soma’’ refers to the living, sensing body, while ‘‘experiencing’’ emphasized being present in the here and now. SE® facilitates completion of defensive body reaction (biological survival responses), stabilizes dysregulated nervous system activity, and enhances resilience through titrated exposure to body-based cues of trauma.
SE® targets core physiological regulation by engaging the autonomic nervous system-both the sympathetic and parasympathetic branches through interoception (visceral sensations), proprioception (body awareness), and kinesthetic feedback (movement), helping survivors of sexual assault learn to tolerate, integrate, and transform stress responses through (i) orienting, which helps survivors re-establish safety by gently directing attention to the present environment, counteracting hypervigilance and dissociation; (ii) felt sense, cultivates awareness of subtle internal sensations, enabling survivors of sexual assault who often experience emotional numbing or disconnection from the body to gradually reconnect with embodied experience; (iii) resourcing provides access to internal or external anchors of safety, strengthening the nervous system’s capacity to regulate distress; (iv) titration involves approaching traumatic material in small, manageable increments, which prevents retraumatization in survivors who may be easily overwhelmed by intrusive memories; (v) pendulation guides the oscillation between states of activation and calm, supporting autonomic flexibility and reducing chronic immobility; (vi) finally, discharging allows incomplete defensive responses to be released through small motor movements or physiological shifts, helping survivors resolve the ‘‘trapped’’ survival energy characteristic of sexual trauma. Together, these mechanisms enable sexual assault survivors to restore autonomic balance, reclaim bodily agency, and rebuild resilience, offering structured ways to reconnect with bodily signals, thereby improving both mental and physical health [16–18].
Group-based SE® provides additional co-regulatory benefits that can be especially valuable in collectivist cultures like Indonesia, where healing through shared experience and low-verbal processing aligns with social norms and resource limitations. It also offers potential advantages, including cost-effectiveness, normalization of trauma symptoms, and peer support, especially in collectivist cultures like Indonesia. Social support has also been shown to buffer PTSD symptoms and improve emotional regulation.
The primary aim of this trial is to evaluate the clinical effectiveness of a culturally adapted group-based SE®intervention. Feasibility and cultural adaptation were conducted in prior stages and are not within the scope of the current trial [19,20]. The hypothesis states that intervention can reduce PTSD symptoms, improve resilience, and foster quality of life for participants, providing an accessible, evidence-based method that respects Indonesia’s cultural context.
Materials and methods
Study design
This study is a parallel-group, randomized controlled trial (RCT) designed to evaluate the effectiveness of a culturally adapted, group-based SE® intervention for Indonesian women survivors of sexual assault with PTSD symptoms. The trial adheres to the SPIRIT 2013 guidelines and is registered at ISRCTN (ISRCTN58257113). The SPIRIT schedule is presented in Fig 1.
Ethical approval was obtained from the Health Research Ethics Committee of Padjadjaran University (No. 1357/UN6.KEP/EC/2023) on 16 November 2023. Written informed consent will be obtained from all participants prior to data collection. Recruitment is scheduled to start in January 2026 and end by June 2026. Written informed consent will be obtained from all participants prior to data collection. Consent will be in written form, signed by participants, and securely stored.
Timeline
Recruitment is planned to begin in January 2026 and end by June 2026 in Bandung, West Java. The intervention is expected to be delivered over a 3-month period, with data analysis projected for completion in 2028. All study procedures will be documented according to CONSORT and SPIRIT reporting standards.
Participants
Eligibility criteria.
Inclusion criteria:
- Female, aged 18 -45 years
- A self-reported history of sexual assault
- PTSD symptoms in the mild to moderate range (PCL-5 score ≥ 39)
- Trauma occurred ≥ 6 months prior to enrollment (to ensure symptom stability and chronicity)
- Not currently receiving trauma-focused psychological treatment or medication within the last 30 days
Exclusion criteria:
- Substance or alcohol misuse
- Ongoing severe mental illness (e.g., psychosis, bipolar disorder, organic brain disorders)
- PTSD symptoms arising in conjunction with a diagnosed medical condition
- Current suicidal ideation requiring emergency care
Recruitment and setting
Participants will be recruited from multiple settings, including psychology bureaus, women’s support organizations, hospitals, and foundations. Recruitment will also take place through online platforms (Instagram, Twitter/X, WhatsApp, LINE). Eligibility will be confirmed through initial screening via phone or in-person, followed by clinical assessment using SCID-5 modules adapted for the Indonesian population. Recruitment is expected to take place from January to June 2026. Written informed consent will be collected before any data collection or participation in sessions. Consent will be documented using a standardized consent form approved by the ethics committee.
To minimize participant attrition, several retention strategies will be implemented: (i) flexible scheduling options for group sessions; (ii) transportation subsidies for eligible participants; (iii) weekly reminders sent via the participant’s preferred contact method (e.g.,WhatsApp or SMS); (iv) emotional check-ins and pre-session grounding will be conducted in person at the beginning of each session, guided by SE® practitioners to support autonomic regulation and participant safety. These practices help orient participants to the present moment and reduce pre-session anxiety. For participants who miss a session, a follow-up emotional check-in will be offered via WhatsApp or SMS to maintain continuity of care and reduce dropout; (v) proactive communication one day prior to each session, including an outline of the next session’s agenda and a short message asking if any support is needed. This message will be sent via WhatsApp or SMS to foster engagement and address potential barriers early.
Randomization and Blinding
Randomization will be conducted by an independent data coordinator using Castor EDC. Group allocation will be concealed from clinical assessors but not from the study coordinator or group facilitators. Blinding of participants is not feasible due to the nature of the intervention. A recruitment and retention flowchart is based on CONSORT guidelines as presented in Fig 2.
Intervention
Group-based SE® Intervention.
Participants in the intervention arm will attend 10 weekly group sessions (3 hours/session) of manualized, group-based SE® intervention based on SE® principles. The intervention emphasizes bottom-up processing of trauma, stabilization of the autonomic nervous system, and completion of incomplete defensive responses. A Module Structure of Group-based SE® sessions is presented in Table 1.
Discontinuation criteria.
Participants may discontinue participation at any time upon their own request, or if the facilitator identifies significant emotional distress requiring individual therapy. In such cases, participants will be referred for appropriate psychological support. As the intervention is non-pharmacological, no modification of dosage or session content will be applied.
Concomitant care
Participants may continue receiving any ongoing counselling or medical care throughout the trial. However, initiation of new trauma-focused therapy during trial participation is discouraged to avoid potential confounding effects on the study outcomes.
Ancillary and post-trial care
Participants who experience psychological distress related to the intervention or trial participation will be offered post-trial psychological support and referral to university counselling services. No financial compensation is provided, but free psychological follow-up will be available on request.
Intervention fidelity and monitoring
Each group-based SE® session will be delivered by trained SE® practitioners and supervised by a senior clinical psychologist. At the end of each session, participants will complete:
- Session Rating Scale (SRS) for therapeutic alliance
- Helpful Aspects of Therapy (HAT) form for qualitative feedback
Grounding exercises will be conducted before and after each session to promote emotional regulation.
Treatment As Usual (TAU)
Participants in the control arm will receive five group counselling sessions (90minutes per session) over five weeks. These sessions focus on psychoeducational counseling session, covering basic mental health support strategies and coping techniques, and are facilitated by licensed psychologist. The decision to provide five 90 minute per sessions is based on evidence from Indonesian research and practice, which showing that survivors of sexual assault typically receive between 4–7 session of psychological support(Ayudia et al. 2025c; Sumekar and Sunawan 2019).
Outcome Measures and Timing.
Outcomes will be measured at four time points:
- T0: Baseline (Week 0)
- T1: Post-treatment (Week 10)
- T2: 1-month follow-up (Week 14)
- T3: 3-month follow-up (Week 22)
Primary outcomes include:.
- PTSD Checklist for DSM-5 (PCL-5): Primary outcome measure assessing PTSD symptoms. Indonesian version Cronbach’s α = 0.93
Secondary outcomes include:
- Connor-Davidson Resilience Scale (CD-RISC-25)
- WHO Quality of Life-BREF (WHOQOL-BREF): Assesses physical, psychological, social, and environmental quality of life. Cronbach’s α range: 0.41–0.77
Other measures include:
- Sociodemographic questionnaire: Collects age, marital status, occupation, education, and medical history.
- Structured Clinical Interview for DSM-5 (SCID-5): Used for diagnostic confirmation of PTSD and exclusion criteria
Sample size
A priori power analysis using G*Power 3.1 estimated a required total sample size of 207 participants (138 intervention, 69 control) to detect a medium effect size (Cohen’s d = 0.5), with α = 0.05, power = 0.80, and accounting for 30% attrition.
The choice of medium effect size (d = 0.5) is based on prior meta-analytical findings from studies evaluating SE® and other body-oriented trauma interventions among individual PTSD or complex trauma symptoms. Specifically, Payne et al [7] and Andersen et al [16–18] report medium to large effect sizes in PTSD symptom reduction following SE® informed interventions. Given the cultural adaptation and group-based format in this study, a conservative medium effect size was deemed appropriate.
Participants will be randomized in a 2:1 allocation ratio using block randomization generated through Castor EDC software.
Data collection and management
Data collection personnel.
Data collection will be carried out by trained research assistants who are postgraduate psychology students with prior experience in research. These assistants will receive additional training on ethical handling sensitive data, trauma-informed interviewing, and scoring procedures for standardized instruments. Data collectors will be blinded to group allocation to minimize bias.
Participant retention and follow-up.
To promote participant retention and ensure complete follow-up, weekly contact and reminder messages will be provided through phone and WhatsApp by research assistants. For participants who discontinue or deviate from intervention protocols, outcome data from all completed assessments will be retained for intention-to-treat (ITT) analysis.
Platform and tools used.
All outcome measures, including PCL-5, CD-RISC-25, WHOQOL-BREF, SRS, HAT will be administered using secure digital forms hosted on REDCap (Research Electronic Data Capture), a HIPAA-compliant, encrypted online platform. In cases where participants have limited internet access or prefer paper-based administrations, hard-copy versions will be made available and later digitized into the REDCap system by data entry personnel.
Confidentiality.
All participant data will be de-identified prior to analysis. Electronic data will be stored on a secure, encrypted university server accessible only to authorized research personnel. Hard-copy documents will be stored in locked cabinets within the Department of Clinical Psychology. Data will be retained for five years after publication, after which it will be permanently deleted. Only the principal investigator and data analyst will have full access to the de-identified dataset
Statistical analysis plan
All statistical analyses will be performed using SPSS version 22.0.
- Descriptive statistics will be used to summarize demographic and clinical characteristics of the participants.
- Baseline differences between groups will be examined using chi-square test for categorical variables and t-test for continuous variables.
- To evaluate treatment effects, linear mixed-effect models will be used to analyse the interaction of time (T0, T1, T2, T3) and group condition (intervention vs control) on primary and secondary outcomes.
- The models will include fixed effects for time, group, and time x group interaction, and random intercepts for participants to account for within subject variability across time points.
- To minimize confounding related to unequal treatment exposure, total professional contact time (minutes) within and outside the study will be logged for each participant. In prespecified secondary analyses, this variable will be included as a covariate in the mixed-effects models. Additional sensitivity analyses will be conducted, including (i) exclusion of participants who receive substantial trauma-focused services outside the protocol, (ii) per-protocol analyses restricted to participants with adequate adherence (≥ 80% of assigned sessions), and (iii) exploratory dose-response models testing the interactions between group assignment and contact time. These steps will allow us to assess whether intervention effects remain robust after adjusting for variation in professional contact time.
- Effect sizes will be reported using Cohen’s d.
- All analyses will follow the intention-to-treat (ITT) principle, including all randomized participants. Missing data will be handled using regression imputation under the assumption that data are missing at random (MAR). Specifically, predictive mean matching will be used to impute missing continuous outcome variables, which is considered appropriate for longitudinal clinical trial data.
To control for the increased risk of Type I error due to multiple comparisons across outcomes, A Bonferroni correction will be applied.
Monitoring
As this is a minimal risk behavioral trial, no formal data monitoring committee (DMC) will be established. Oversight will be provided by a senior clinical psychologist independent from the intervention facilitators. No interim analyses are planned. The trial may be stopped early by the principal investigator or the ethics committee in the event of safety or ethical concerns.
SE® practitioners will monitor participant safety through pre- and post-session grounding, and report any adverse events to the university ethics board. Internal auditing will be conducted every three months by the Department of Clinical Psychology’s research ethics monitoring team, which operates independently from the investigators.
Discussion
This trial represents the first RCT of culturally adapted, group-based SE® intervention for Indonesian women survivors of sexual assault. It addresses a critical treatment gap by targeting bottom-up regulation of trauma responses in a low-resource and collectivist context. The group format offers additional benefit of cost-effectiveness, normalization of trauma symptoms, and peer-based co regulation, which are congruent with Indonesian cultural values. Findings will contribute to the broader literature on culturally adapted trauma interventions, which remains limited in Southeast Asia.
If effective, this body-based group intervention could serve as a scalable trauma recovery model in low-resource and collectivist cultural contexts. The study also seeks to contribute to the broader literature on cultural adaptation of trauma therapies, which has been underexplored in Southeast Asia. Findings may inform mental health policy and service delivery, especially for gender-based violence survivors lacking access to individualized therapy.
Limitations
This study has several limitations. First, despite efforts to balance treatment exposure, a discrepancy in contact time remains between the SE® intervention (10 sessions x 180 minutes) and the TAU arm (5 sessions x 90 minutes). This discrepancy introducing bias. However, the design of TAU reflects the real-world availability of services in Indonesia, where survivors of sexual assault typically have limited and sporadic access to structured trauma-focused therapy. To address this issue, will be committed to controlling for total minutes of professional contact as a covariate in secondary analyses. Sensitivity analyses will also be conducted to test whether outcomes remain robust after adjusting for contact time.
Second, while the number of session differs between arms, it is important to emphasize that the aim of this trial is not to determine which treatment is superior, but rather to evaluates the effectiveness of culturally adapted SE® intervention relative to the benchmark of usual care in Indonesia. In this sense, TAU serves as a pragmatic comparator that mirrors local service provision, rather than a dose-matched control condition. This design enhances ecological validity and translational relevance, though it limits strict comparability of treatment ‘‘dose.’’
Third, TAU is based on psychoeducational counselling rather than trauma-specific intervention. While this may reduce comparability in therapeutic content, it pragmatically reflects current service delivery in Indonesia, thus increasing ecological validity and translational relevance.
Fourth, blinding of participants is not feasible due to the nature of the intervention, which may increase the risk of expectancy effects. Finally, the trial is conducted within one cultural and geographical setting, which may limit generalizability to other populations. Nonetheless, focus on cultural adaptation offers insight that could guide implementation in similar low-resource and collectivist context.
Conclusions
This trial aims to generate evidence on the clinical effectiveness of a group-based SE® intervention that has been culturally adapted for Indonesian survivors of sexual assault with PTSD symptoms. If successful, the study could inform service delivery and policy in low-resource settings and strengthen global knowledge on the role of body-oriented trauma therapies.
Acknowledgments
We thank all potential collaborators and trauma support centers for future participation.
Dissemination plans
The findings of this study will be disseminated through multiple channels. First, the primary results will be submitted for publication in peer-reviewed international journal focusing on trauma, global mental health, and psychotherapy. Findings will also be presented at national and international conferences related to psychology, psychiatry, and public health.
To ensure practical impact, dissemination will extend beyond academic forums. Result will be shared with Indonesian stakeholders, including mental health professionals, non-governmental organization (NGOs) supporting women survivors of gender-based violence, and community organizations engaged in trauma recovery and women’s health.
Moreover, accessible formats such as policy briefs, podcasts, and community discussions will be used to reach a wider audience including survivors, caregivers, and advocacy groups. This strategy is intended to maximize the potential for clinical translation, inform culturally appropriate trauma care practices in low-resource settings, and support the scalability of group-based SE® intervention in Indonesia.
The full protocol, anonymized dataset, and statistical code will be shared publicly via the Open Science Framework (OSF) repository.
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