Evaluation of a PTSD psychoeducational program for psychiatric inpatients

Journal of Mental Health, April 2005; 14(2): 121 127 Evaluation of a PTSD psychoeducational program for psychiatric inpatients SARAH I. PRATT, STANLEY ROSENBERG, KIM T. MUESER, JOSEPH BRANCATO, MICHELLE SALYERS, MARY KAY JANKOWSKI, & MONICA DESCAMPS New Hampshire-Dartmouth Psychiatric Research Center, Department of Psychiatry, Dartmouth Medical School, Concord, New Hampshire, USA Abstract Background: Persons with severe mental illness are at high risk for trauma and posttraumatic stress disorder (PTSD), but trauma-focused interventions are rarely delivered. Aim: The purpose of this study was to evaluate the feasibility of providing a psychoeducational program for individuals with SMI and PTSD in a psychiatric hospital, and to assess gains in knowledge and satisfaction with the program. Method: Seventy inpatient participants who met criteria for PTSD attended three sessions of a psychoeducational program using a group format of video and discussion. The participants completed a knowledge of PTSD questionnaire before and after the education programme. Results: Participants demonstrated significant increases in knowledge about trauma and PTSD, and reported high levels of satisfaction with the program. Conclusion: Findings support the use of this intervention as a first step in increasing knowledge about PTSD and stimulating motivation to seek future treatment. Declaration of Interest: None. Keywords: PTSD, schizophrenia, trauma, psychoeducation. The lifetime prevalence of trauma exposure among people who are admitted to a psychiatric hospital, many of whom have a serious mental illness (SMI), is extremely high. The rate of physical and sexual abuse in psychiatric inpatients may range from 53 to 81% (Goodman, Dutton, & Harris, 1997), and overall trauma exposure among psychiatric inpatients may vary from 61 to 100% (McFarlane, Bookless, & Air, 2001; Shaw, McFarlane, Bookless, & Air, 2002). About 90% of people with SMI have experienced at least one traumatic event and most have been multiply traumatized (Goodman et al., 1997). Estimates of the rate of post-traumatic stress disorder (PTSD) among individuals with SMI ranges from 29 43% (Mueser, Rosenberg, Goodman, & Trumbetta, 2002), compared with 8 12% in the general population (Breslau, Davis, Andreski, & Peterson, 1991; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). Trauma exposure in the SMI population is associated with worse outcome, including more severe psychotic symptoms, suicidality, hostility, anxiety, and depression (Briere, Woo, McRae, Correspondence: Sarah I. Pratt, PhD, New Hampshire-Dartmouth Psychiatric Research Center, Main Building, 105 Pleasant Street, Concord, NH 03301, USA. Tel + 1 603 271 5747. Fax: + 1 603 271 5265. E-mail: Sarah.I.Pratt@Dartmouth.edu ISSN 0963-8237 print/issn 1360-0567 online # Shadowfax Publishing and Taylor & Francis Group Ltd DOI: 10.1080/09638230500066356

122 S. I. Pratt et al. Foltz, & Sitzman, 1997; Craine, Henson, Colliver, & MacLean, 1988; Goodman et al., 1997). Exposure to interpersonal violence, in particular, is also correlated with more frequent hospitalizations and more time in the hospital (Briere et al., 1997). Although trauma exposure and PTSD are common in people with SMI, many hospitalized individuals are not given this diagnosis and trauma-focused interventions are rarely delivered by treating clinicians (Rosenberg et al., 2001). Clinicians treating individuals with SMI appear to focus on prominent symptoms such as hallucinations, delusions, suicidality and severe anxiety, to the exclusion of trauma-related symptoms such as nightmares, flashbacks, and avoidance. Nevertheless, the recent recognition of the high prevalence of PTSD in people with SMI and the associated worse clinical outcomes have stimulated interest in treating PTSD in this population. A variety of interventions have been developed for PTSD, including cognitive behavior therapies (e.g., exposure therapy, cognitive restructuring) and pharmacotherapy (Foa, Keane, & Friedman, 2000). These approaches have not been systematically evaluated in individuals with SMI, either in outpatient or inpatient settings (Rosenberg et al., 2001). Given the prevalence of trauma in this group, efforts are underway to develop and evaluate interventions for individuals with PTSD and SMI. Because trauma is often a neglected aspect of their lives, there is a need to educate consumers about trauma and PTSD so that they can participate in an informed way in shared decision-making about treatment alternatives. The objective of this pilot study was to assess the feasibility of providing a brief, groupbased psychoeducational program for individuals with SMI and PTSD in a state psychiatric hospital, and to evaluate gains in knowledge and satisfaction with the program. A threesession psychoeducational program, which is described below, was designed to inform people about the consequences of trauma, the symptoms of PTSD and treatment options for PTSD. The program was not designed as a therapeutic intervention to treat the symptoms of PTSD, but rather to educate consumers about the nature of the disorder and possible treatment options. We hypothesized that, after completing the program, participants would: (1) demonstrate increased knowledge regarding trauma and PTSD; (2) report satisfaction with the intervention; (3) report neither significant exacerbations nor significant reductions in psychiatric symptoms; (4) express an interest in seeking treatment for their PTSD. Methods The study was conducted at New Hampshire Hospital (NHH), the only state psychiatric hospital in New Hampshire. Routine screening for PTSD in patients over age 18 began on the three acute care units of the hospital in mid-october 2000. The PTSD Psychoeducational Program was offered beginning in late December 2000. Evaluation of the program occurred between late December 2000 and May 2003. Participants Participants were 70 hospitalized individuals who met criteria for PTSD following routine screening (see below). All individuals attended all three sessions of the program, and had complete evaluation data. The number of males and females who participated was roughly equal (34 females, 36 males). Primary psychiatric diagnoses were available for 64 of the participants. Of these individuals, 34% (n = 22) were diagnosed with a schizophreniaspectrum disorder, 45% (n = 29) were diagnosed with a mood disorder, and the remaining individuals (n = 13) had other diagnoses (e.g., psychosis NOS).

Psychoeducational program for PTSD inpatients 123 PTSD Psychoeducational Program The PTSD Psychoeducational Program included a videotape of three simulated individual sessions between a female therapist and a female client that depicted discussions about trauma and PTSD. The tape was designed to be viewed by participants (either individually or in a group) together with a trained clinical facilitator. The video had built-in stopping points and a manual with suggested discussion questions to facilitate interactive learning and group support. The first session addressed the difference between stressful and traumatic life events, and introduced the term post-traumatic stress disorder. The second session focused on the symptoms of PTSD, providing examples of each of the three symptom clusters (re-experiencing symptoms, avoidance symptoms, and over-arousal symptoms). The third session focused on common problems associated with PTSD (e.g., difficulties with relationships, mood disturbance, substance abuse) and treatment alternatives. Participants were provided with handouts summarizing the information presented in each segment of the video. Each of the three segments lasted approximately 15 20 minutes. Viewing the segments together with discussion typically required three 45 60-minute sessions. Measures As part of the standard admission interview, ward psychologists invited individuals to complete a web-based survey that included: a modified version of the Trauma History Questionnaire (THQ: Green, 1996), the PTSD Symptom Checklist (PCL: Blanchard, Jones-Alexander, Buckley, & Forneris, 1996), and the Knowledge of PTSD Test (KPTSD), a 15-item multiple-choice test designed for this project to assess knowledge regarding PTSD. The THQ screens for exposure to physical abuse or violence (9 questions); sexual abuse (3 questions); motor vehicle or other accidents (2 questions); death of a loved one (1 question); and other traumatic events (1 question). Both the THQ and PCL have been shown to have good reliability and construct validity in the SMI population (Mueser et al., 2001). Upon completion of the psychoeducational program, individuals completed the KPTSD again and completed a 10-item Satisfaction Scale developed for the study to evaluate satisfaction with the program and motivation to pursue treatment in the future. Procedure All individuals who agreed to the screen and met PCL criteria for PTSD were invited to participate in the program. The program was delivered by psychologists and pastoral counselors at NHH who co-led groups on a rotating basis. All three sessions were held during the same week to accommodate the relatively short average length of stay (10 days) at NHH. In most cases, the three segments were shown on different days to allow sufficient time for processing the information, although consecutive viewing of segments was an option. At the end of the third session, the group leaders invited participants to complete the KPTSD and the Satisfaction Scale. Clinicians facilitating the program were made aware of locally available trauma-focused therapy for individuals who expressed an interest in outpatient treatment after discharge from the hospital. Results The study sample consisted of 518 individuals consecutively admitted to NHH between late December 2000 and early May 2003 who agreed to complete the PTSD screening

124 S. I. Pratt et al. assessment. All 518 reported exposure to trauma, with an average of 6.5 (SD = 3.4) traumatic events reported by the group. Forty percent of those screened reported exposure to five or fewer traumatic events. Forty-five percent reported exposure to between six and ten traumatic events, and 15% reported exposure to more than ten traumatic events. Of the 518 individuals who completed the screening, 265 (51%) were positive for PTSD on the PCL. For a subsample of those screened, detailed information on attendance and reasons for not completing the psychoeducational program were tracked. During a 15-month period, from December 2000 March 2002, 150 individuals were referred to the program. Of those, 98 (65%) attended at least one session. Most of the referred individuals who did not attend the program were discharged before a group was offered (43 individuals); however, seven people refused to attend and two were judged too psychiatrically unstable. Of the 98 individuals who attended the program, 82 (84%) attended two or more sessions, and 62 (63%) attended all three sessions. Most of the individuals who attended at least one session but did not complete the program (20 individuals) were discharged or transferred to another unit before the third session was offered; however, nine individuals refused groups or selected other concurrent groups offered at the hospital, and four individuals were deemed too psychiatrically unstable. Complete data was available for 70 individuals (34 females and 36 males) referred to the program between December 2000 and March 2002. Of those, 45 attended at least one session and 33 completed the program. Reasons for nonattendance in this subsample included early discharge (75%), refusal (10%), and concurrently scheduled meetings or programming (15%). It should be noted that the hospital provides a rich and varied program of groups, and clients have a choice of several possible groups to attend at any given time of the day. We performed a repeated measures analysis of variance (ANOVA) to evaluate change in KPTSD scores over time and to evaluate whether there were differences in knowledge gain as a function of gender and diagnosis. The dependent variable was percentage correct on the KPTSD before and after the program, and gender and diagnosis (schizophrenia-spectrum disorders or mood disorders) were the independent variables. The time effect for this ANOVA was significant (F = 14.54, df = 1, 69, p 5 0.0001), with average scores on the KPTSD improving from 70% correct to 87% correct. Neither the main effects for diagnosis and gender nor the interaction effects for time by diagnosis and time by gender were significant, indicating that gains in knowledge of PTSD did not differ based on gender or diagnosis. A summary of the ratings obtained from the Satisfaction Scale is displayed in Table I. Overall, individuals expressed high levels of satisfaction with the program. Most individuals indicated that the program helped them learn more about PTSD and treatment options. As expected, although most individuals reported that the program was helpful, few reported that it resulted in significant symptomatic relief. On the other hand, only a small minority of participants reported that the program made them feel worse about their past experiences. In terms of willingness to seek future treatment, most individuals reported being more likely to seek treatment for trauma and/or PTSD after participating in the program. Finally, a large majority found the program easy to understand, suggesting that neither acuity of symptoms nor cognitive difficulties interfered with perceived ability to comprehend the educational material. Overall, the program was very well tolerated and negative reactions to it were rare. Participation in group discussions during the sessions varied, with discussion of past physical abuse more common than discussion about past sexual abuse. Very few

Psychoeducational program for PTSD inpatients 125 Table I. Satisfaction with the PTSD video. Satisfaction statements Strongly disagree Disagree Neutral/ Don t know Agree Strongly agree Learn more about PTSD 1.5 4.5 6.1 45.5 42.4 Learn more about problems relating to trauma 0.0 6.1 1.5 47.0 45.5 Learn about treatment options 6.1 1.5 4.5 45.5 42.4 Would recommend to a friend 4.6 7.7 10.8 43.1 33.8 Am more likely to seek treatment for trauma/ 7.6 6.1 10.6 40.9 34.8 PTSD Feel less distress about my symptoms 13.8 23.1 27.7 20.0 15.4 Feel worse about my past experiences 30.3 34.8 21.2 9.1 4.5 Find information easy to understand 0.0 1.5 9.1 37.9 51.5 Find information helpful 3.0 3.0 3.0 51.5 39.4 Feel better able to cope with trauma-related problems 9.1 13.6 28.8 28.8 19.7 Note: The values represent percentages of participants choosing that level of agreement with the statement. participants had overt psychotic symptoms, although some individuals with schizophreniaspectrum disorders recounted past abuse experiences that appeared to be delusional. During participation in the program, some individuals tended to attribute all of their psychiatric symptoms to PTSD. This was more common among individuals with schizophrenia-spectrum disorders than mood disorders. Leaders avoided lengthy discussions about participants psychiatric diagnoses or whether PTSD was in fact their only valid diagnosis. Discussion These results showed it was feasible to implement the PTSD Psychoeducational Program among psychiatric inpatients. Most of the individuals who were invited to attend the program participated. Individuals who attended at least one session but did not complete the program generally failed to do so because they were discharged before the third session was held. Based on feedback from treatment teams, we were not aware of significant exacerbations in trauma-related or other psychiatric symptoms. This is a particularly positive finding considering concerns that some clinicians have had that focusing on past traumatic experiences could open a Pandora s box that they might be unable or unqualified to close. The findings obtained suggest that psychiatric hospitalization may represent an opportune time to assess and provide basic education about trauma and PTSD. Nevertheless, a limitation of this study is that the PCL was not repeated following completion of the program; therefore, we were unable to assess changes in psychiatric symptoms in a standardized way. Results also demonstrated that participants were capable of learning about trauma and PTSD, with average scores on the KPTSD increasing from 70% to 87% correct. This indicates that hospitalized individuals are able to acquire new information despite acute symptoms, which is in line with studies of social skills training in inpatient settings (McKee, Hull, & Smith, 1997; Mueser, Bellack, Douglas, & Wade, 1991). Findings indicate a ceiling effect on the measure of knowledge about PTSD symptoms. Despite this ceiling effect, we were able to demonstrate that hospitalized individuals could benefit from the program in terms of increased knowledge about PTSD.

126 S. I. Pratt et al. Responses on the Satisfaction Scale indicated that a large majority of participants found the psychoeducational program helpful and easy to understand. A substantial proportion of participants also reported that they would recommend the program to a friend. As expected, the psychoeducational program did not produce improvements in participants perceived ability to cope with their PTSD symptoms. Cognitive-behavior therapy enjoys the strongest support for treating the symptoms of PTSD and associated problems, with little evidence that psychoeducation alone is an effective treatment (Foa et al., 2000). Although psychoeducation alone is unlikely to produce meaningful clinical change in functional outcome, its role in psychiatric treatment generally, and PTSD treatment in particular, should not be underestimated. Providing information about common responses to trauma and frequently observed patterns of symptomatology can help to normalize posttraumatic reactions. Psychoeducation may also prevent clients from misinterpreting traumarelated symptoms. For example, an individual with schizophrenia experiencing flashbacks may misinterpret them as hallucinations. Enhancing understanding of trauma and its consequences may facilitate categorization of symptoms and reactions as trauma-related, illness-related or dually determined. Psychoeducation, particularly information about treatment alternatives, may also help to instill hope and motivation to seek help. In fact, most individuals indicated that the psychoeducational program increased their desire to seek treatment for their trauma-related symptoms. However, we have no information about whether individuals who received the program followed through with post-discharge PTSD treatment. Finally, consumers need information and psychoeducation in order to engage in shared decision-making with mental health providers (Mueser et al., 2002). The primary limitation of this study is the fact that it was not a controlled evaluation of the program and no follow-up assessment was conducted. In addition, the program was offered in a setting with a homogeneous patient population, primarily Caucasian, relatively welleducated individuals from a predominantly rural state (NH). Future evaluations of the program should be conducted in more ethnically diverse settings that include both inpatients as well as outpatients, and should include a care as usual group. Finally, it would be interesting to evaluate whether participating in the program actually resulted in increased follow-through on clients efforts to get trauma-based treatment. These findings support the use of this promising psychoeducational intervention as a first step in increasing knowledge about trauma and PTSD and stimulating motivation to seek future treatment. This is important given the need to attend to trauma-related disorders in individuals with SMI, many of whom report that being admitted to a psychiatric hospital can, in itself, be a traumatic experience. Additional work is warranted to understand the effects of this psychoeducational program, and on interventions designed to treat posttrauma disorders in clients with SMI. References Blanchard, E. P., Jones-Alexander, J., Buckley, T. C., & Forneris, C. A. (1996). Psychometric properties of the PTSD Checklist. Behavior Therapy, 34, 669 673. Breslau, N., Davis, G. C., Andreski, P., & Peterson, E. (1991). Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry, 48, 216 222. Briere, J., Woo, R., McRae, B., Foltz, J., & Sitzman, R. (1997). Lifetime victimization history, demographics and clinical status in female psychiatric emergency room patients. Journal of Nervous and Mental Disease, 185, 95 101. Craine, L. S., Henson, C. E., Colliver, J. A., & MacLean, D. G. (1988). Prevalence of a history of sexual abuse among female psychiatric patients in a state hospital. Hospital and Community Psychiatry, 39, 300 304.

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