A cognitive-behavioral treatment program for posttraumatic stress disorder in severe mental illness.

Clients with severe mental illnesses (SMI) such as schizophrenia and bipolar disorder have high rates of exposure to trauma over their lives, and are at sharply increased risk for the development of posttraumatic stress disorder (PTSD). However, at present there are no validated treatments of PTSD in the SMI population. In this article we describe a new cognitive-behavioral The authors appreciate the comments of Katie Acker and Elisa Bolton on this article. This article was prepared with support from NIMH grant #MH64662-01. treatment program for PTSD in clients with SMI. We begin with a brief review of the research on trauma and PTSD in clients with SMI. Next, we summarize findings on the treatment of PTSD in the general population, followed by considerations in the development of a treatment program for clients with SMI. We then describe our program, which is based primarily on the principles of cognitive restructuring and involves treatment closely integrated with the ongoing provision of comprehensive services for the SMI. We conclude with a description of how common challenges of working with clients with SMI are handled in the treatment program, including substance abuse, cognitive impairment, and psychosis. Two companion articles to this one provide clinical examples of clients treated in this program (Hamblen, et al., in press) and summarize the results of a pilot study of the program that establish its feasibility and clinical promise The term ''severe mental illness'' (SMI) is widely used to describe individuals with a psychiatric disorder that is characterized by pervasive impairments across different areas of functioning, including social relationships, work, leisure, and self-care It has long been recognized that persons with SMI are at increased risk for trauma over the lifetime attempting to address the needs of trauma survivors In this article we describe a recently developed treatment model for PTSD in persons with SMI. Illustrative cases of three clients treated with the model are included in a companion paper We begin this article with a brief review of trauma, PTSD, and their assessment in persons with SMI. We next provide a rationale for focusing treatment on PTSD, rather than on the broader range of consequences of trauma, and summarize a model which posits that PTSD plays a central role in mediating the negative effects of trauma on outcome of SMI. We then discuss what is known about the treatment of PTSD in the general population, followed by consideration of adaptations needed to treat PTSD in persons with SMI. We briefly outline the theoretical basis for cognitivebehavioral treatment of PTSD, and describe a treatment approach developed for this population. We then consider how common problems in treating clients with SMI are handled in the approach, including substance abuse, cognitive impairment, and psychosis. TRAUMA IN THE GENERAL POPULATION AND THE SMI POPULATION Psychological trauma refers to the experience of an uncontrollable event perceived to threaten a person's sense of integrity or survival Abundant evidence documents that rates of lifetime trauma in the general population are high. In the National Comorbidity Study, 56% of respondents reported exposure to a traumatic event during their lives While trauma is common in the general population, persons with SMI are even more likely to be traumatized. Between 34% and 53% of clients with SMI report childhood sexual or physical abuse (Darves-Bornoz, victimization with rates ranging as high as 77% to 97% for episodically homeless women Traumatic experiences in clients with SMI are related to both the severity of psychiatric symptoms and increased use of acute care services. In particular, clients with SMI who have a history of trauma report more severe symptoms, such as hallucinations, depression, and anxiety PTSD IN CLIENTS WITH SMI PTSD is defined by three types of symptoms, including reexperiencing the trauma, hyperarousal, and avoidance of trauma-related stimuli, which persist or develop at least one month after exposure to a trauma (APA, 1994). Recent estimates of lifetime prevalence of PTSD in the general population range between 8% and 12% Studies of PTSD in clients with SMI indicate higher rates of PTSD. Eight studies with clients with SMI have examined the prevalence of PTSD in the SMI population. One study of first admissions for psychosis reported a rate of 14%, and the remaining seven studies reported rates ranging between 28% and 43% Treatment for PTSD in Persons with SMI 111 Switzer et al., 1999). As in the general population The high rates of PTSD in clients with SMI are consistent with their increased exposure to trauma, but also suggest an elevated risk for developing PTSD given exposure to a traumatic event compared to the general population. In a sample of clients drawn from a large health maintenance organization, for example, RELIABILITY AND VALIDITY OF TRAUMA AND PTSD ASSESSMENTS IN CLIENTS WITH SMI The validity of people's accounts of traumatic events has been a topic of much controversy, especially concerning reports by adults of childhood sexual abuse K. T. Mueser et al. While the accuracy of reports of victimization is difficult to ascertain, the reliability (or consistency) of reports over time can be more easily determined. Temporal reliability of trauma reports is a necessary, but not sufficient condition to establish validity. The few studies of the temporal stability of trauma exposure measures in non-SMI individuals report fair to moderate test-retest reliability Two recent studies have evaluated the reliability and validity of PTSD assessments in clients with SMI. We have reviewed research documenting that trauma exposure and PTSD can be measured reliably in the SMI population, and studies showing that the prevalence of PTSD in clients with SMI exceeds that in the general population. Furthermore, trauma and PTSD are correlated with worse functioning and higher service utilization among clients with SMI. In the next section we address the question of why it is important to focus on the treatment of PTSD, rather than more broadly addressing the effects of trauma, in clients with SMI. Treatment for PTSD in Persons with SMI 113 WHY FOCUS ON PTSD IN CLIENTS WITH SMI? There are several reasons for focusing treatment efforts on PTSD in persons with SMI, rather than attempting to address the broader range of effects associated with trauma exposure in this population. First, PTSD is a type of psychopathology, whereas trauma exposure is not. Exposure to trauma is a life event (or series of life events) that may or may not be associated with negative psychological consequences, depending on factors such as resiliency and the availability of social support Second, there is substantial research on PTSD and its treatment in the general population, with ample evidence supporting the effectiveness of psychological intervention Third, there are both empirical and theoretical reasons for hypothesizing that PTSD mediates the impact of trauma on worsening the course of SMI through both direct and indirect means 114 K. T. Mueser et al. It appears likely that PTSD impacts the relationships between trauma, more severe symptoms, and higher use of acute care services in clients with SMI, both directly (via symptoms) and indirectly (via correlates such as substance abuse and retraumatization) In the next section we discuss the treatment of PTSD in the general population, followed by the development of our model for treating PTSD in clients with SMI. TREATMENT OF PTSD IN THE GENERAL POPULATION There is a growing evidence from studies of the general population that well delineated, theoretically based treatment models are Treatment for PTSD in Persons with SMI 115 effective in the treatment of PTSD. In 1997, the International Society for Traumatic Stress Studies (ISTSS) established a Treatment Guidelines Task Force, and this group has published PTSD treatment guidelines Within this class of interventions, exposure therapy had the most studies supporting its efficacy Following exposure, cognitive restructuring (also called cognitive therapy), had the second strongest empirical support exposure therapy or cognitive restructuring alone CONSIDERATIONS IN TREATING PTSD IN CLIENTS WITH SMI In developing our cognitive-behavioral intervention for PTSD in clients with SMI we opted to employ cognitive restructuring rather than imaginal and in vivo exposure as the primary treatment strategy for several reasons. First, clients with SMI are exquisitely sensitive to the effects of stress Second, surveys of trauma exposure in clients with SMI indicate much higher rates of childhood sexual abuse than in the general population Third, there is extensive evidence documenting that cognitive restructuring can be effectively implemented in clients with SMI, with multiple randomized controlled trials showing that it is effective at reducing persistent psychotic symptoms In addition to the selection of cognitive restructuring as the primary therapeutic technique, several other considerations were involved in developing our program. Because cognitive deficits are often present in clients with SMI PTSD is but one of a host of possible problems clients with SMI face, and it is critical that its treatment be carefully integrated into the overall treatment a client receives. Specifically, in order for PTSD to be effectively treated, there must be ongoing communication between the therapist and other members of the clients' treatment team, especially the case manager, whose role is to coordinate 118 K. T. Mueser et al. the various aspects of the client's treatment. This permits the therapist to be aware of critical issues the client is experiencing, and for the case manager to support and reinforce the teaching that takes place in the CBT. To accommodate this, we created guidelines to establish and maintain ongoing contact between the therapist and case manager throughout the intervention, including the therapist attending treatment team meetings to communicate about clients' PTSD treatment vis-a-vis other areas of their treatment plan. Thus, our treatment program for PTSD was designed to address the unique needs of clients with SMI by minimizing unnecessary stress through the use of cognitive restructuring rather than therapeutic exposure strategies, simplifying the teaching strategies and ensuring high flexibility of the model to account for cognitive deficits common in this population, and developing guidelines to facilitate the integration of the PTSD treatment into the client's overall psychiatric care. In the next section we describe our treatment program. A COGNITIVE-BEHAVIORAL TREATMENT PROGRAM FOR PTSD IN SMI We begin with an overview of the program, followed by a description of the logistics of delivering the treatment, such as client eligibility and assessment, the number and pacing of sessions, and coordination with psychiatric treatment. We then describe the core treatment components of the program, including psychoeducation, breathing retraining, and cognitive restructuring. We conclude by considering how special problems in treating clients with SMI are handled in the treatment program. Overview of the Program The PTSD treatment program is an individual, time-limited, cognitive-behavioral intervention for PTSD in clients with SMI who are receiving ongoing services for their SMI, such as case management, pharmacological treatment, and psychosocial rehabilitation. Therapists typically work with clients on their PTSD over a three-to six-month period of time. Therapy is coordinated with other treatment through regular contacts with the client's treatment team and involvement of the case manager (or other team Treatment for PTSD in Persons with SMI 119 member with a strong therapeutic alliance with the client) during the process of planning for termination towards the end of program. The major therapeutic thrust of the program is first on providing information to help clients conceptualize their trauma-related symptoms as a common, learned response to a traumatic, often lifethreatening event or situation, and second, on teaching clients the skill of cognitive restructuring to enable them to manage and change their negative emotions through identifying and challenging maladaptive thoughts and beliefs which are often related to the trauma. Because the primary focus of the program is on teaching information and skills believed to be critical for a resolution of the PTSD, homework is regularly assigned and concerted attention is given to ensuring that clients are able to use skills learned in sessions in their day-to-day lives. Intervention is delivered on the basis of a treatment manual, with guidelines that provide both clear structure and goals, while also permitting flexibility in tailoring the material to clients' personal experiences and current circumstances, and compensating for possible liabilities related to their mental illness (e.g., cognitive impairment, affective instability)