Karen J. Cusack

Exposure-based cognitive-behavioral treatment of PTSD in adults with schizophrenia or schizoaffective disorder : A pilot study

In an open trial design, adults (n=20) with posttraumatic stress disorder (PTSD) and either schizophrenia or schizoaffective disorder were treated via an 11-week cognitive-behavioral intervention for PTSD that consisted of education, anxiety management therapy, social skills training, and exposure therapy, provided at community mental health centers. Results offer preliminary hope for effective treatment of PTSD among adults with schizophrenia or schizoaffective disorder, especially among treatment completers (n=13). Data showed significant PTSD symptom improvement, maintained at 3-month follow-up. Further, 12 of 13 completers no longer met criteria for PTSD or were considered treatment responders. Clinical outcomes for other targeted domains (e.g., anger, general mental health) also improved and were maintained at 3-month follow-up. Participants evidenced high treatment satisfaction, with no adverse events. Significant improvements were not noted on depression, general anxiety, or physical health status. Future directions include the need for randomized controlled trials and dissemination efforts.

Unrecognized Trauma and PTSD among Public Mental Health Consumers with Chronic and Severe Mental Illness

Lifetime prevalence of traumatic events and current PTSD was assessed among 142 mental health consumers with serious mental illness served by a psychosocial rehabilitation day program. Lifetime exposure to trauma was high (87%). The rate of PTSD based on the PTSD Checklist (PCL) was also high (19–30% depending on different scoring criteria). Overall, the PCL had strong internal reliability for this sample. Documentation of trauma and PTSD was exceptionally low in medical records. Results suggest that trauma and PTSD are significantly overlooked in the public mental health system. Improved recognition of trauma and PTSD are needed in order to provide meaningful services to this highly vulnerable population.

TRAUMA WITHIN THE PSYCHIATRIC SETTING: A PRELIMINARY EMPIRICAL REPORT

Recent studies show that trauma victim(Mueser et al., 1998; Switzer et al., 1999). Posttraumatic stress disorder (PTSD) is ization (51%–98%) and posttraumatic stress disorder (42%) are highly prevalent among considered to be chronic and debilitating, with high rates of co-occurring Axis I and persons with severe mental illness (schizophrenia, bipolar disorder) who are served Axis II mental health disorders (Keane & Wolfe, 1990), and with serious adverse efwithin public-sector mental health clinics fects on social, familial, and occupational functioning (Frueh, Turner, Beidel, & CaKaren J. Cusack, Ph.D., is a Project Director in hill, 2001). Furthermore, evidence indithe South Carolina Department of Mental cates that PTSD is associated with nearly Health. B. Christopher Frueh, Ph.D., is an Assothe highest rate of medical and mental ciate Professor in the Department of Psychiatry and Behavioral Sciences at the Medical Univerhealth service use, making it one of the sity of South Carolina, and a Staff Psychologist costliest mental disorders (Greenberg et at the Veterans Affairs Medical Center, Charlesal., 1999). Given this, it is clear that trauma ton, South Carolina. Thom Hiers, Ph.D., is Exhas a prominent impact on public health ecutive Director of the Charleston/Dorchester Mental Health Center. Samantha Suffolettaand it should be of great interest to those Maierle, Ph.D., is a Project Coordinator in the concerned with public mental health adDepartment of Psychiatry and Behavioral Sciministration and policy. However, trauma ences at the Medical University of South Carosurvivors tend to receive inadequate menlina. Sandy Bennett, BSW, LMSW, is a Social tal health services (Amaya-Jackson et al., Worker and Consumer Affairs Coordinator in the South Carolina Department of Mental 1999; Frueh et al., 2002) and they may, in Health. fact, be especially vulnerable to additional This work was partially supported by a grant traumatic and/or iatrogenic experiences from the Ensor Foundation to Dr. Cusack, and that may routinely occur within the psychia grant from the National Institute of Health (MH01660) to Dr. Frueh. atric setting (Cohen, 1994; Frueh et al., Address for correspondence: Karen J. Cu2000). sack, Ph.D., Charleston/Dorchester Community Clearly, modern psychiatric hospitals are Mental Health Center, 701 East Bay St., MSC/ a far cry from the “Old Bedlam” of London, 1110, Charleston, SC 29403. E-mail: KJC42@ where “Inmates were chained, whipped, and CHAMHC.DMH.STATE.SC.US.

Workshop-based training in trauma-focused CBT: an in-depth analysis of impact on provider practices.

Despite evidence that more intensive methods are more effective, many clinical settings continue to train practitioners using workshops. To more fully understand the strengths and limitations of workshops, the present investigation studied changes in practitioner behavior following a workshop in trauma-focused cognitive-behavioral therapy (TF-CBT). A chart review indicated no changes in TF-CBT use following the training, although therapists indicated that CBT was the most effective treatment for traumatized youths and was their primary approach to treating trauma. Analysis of client factors indicated weak relationships between technique use and treatment need. Implications of these findings for future training efforts are discussed.

The need for trauma assessment and related clinical services in a state-funded mental health system.

Previous data show that trauma is highly prevalent in public sector consumers and is associated with severe mental illness and high service use costs. Despite this, evidence suggests that trauma victims tend to go unrecognized and to receive inadequate mental health services. We surveyed all facilities (6 inpatient, 17 outpatient) within the South Carolina Department of Mental Health about their current services for trauma victims. Results indicate that most public mental health facilities do not routinely evaluate trauma history in an adequate manner or provide specialized trauma-related services. Implications and future directions are addressed, including the current trauma initiatives of many state-funded systems.

Disseminating Evidence-Based Practices for Adults With PTSD and Severe Mental Illness in Public-Sector Mental Health Agencies

Posttraumatic stress disorder (PTSD) remains largely untreated among adults with severe mental illnesses (SMI). The treatment of psychotic symptoms usually takes precedence in the care of adults with SMI. Such oversight is problematic in that PTSD in SMI populations is common (19%-43%), contributes a significant illness burden, and hinders mental health care. Yet few public-sector mental health agencies routinely provide specialized services for PTSD. The purpose of the article is to describe strategies and efforts to disseminate trauma-focused empirically based practices in a public-sector mental health system. Identified challenges include limited resources and commitment; knowledge deficits, attitudes, and biases; and limited practice accountability at provider, facility, and system levels. Proposed strategies for overcoming these challenges are to set clear goals, nurture broad-based organizational commitment and key stakeholder involvement, implement specialty training efforts to provide information and change attitudes, provide ongoing supervision, conduct fidelity monitoring, and ensure accountability to the extent possible.

Cognitive-behavioral treatment for PTSD among people with severe mental illness: a proposed treatment model.

The lifetime prevalence of posttraumatic stress disorder (PTSD) is about 8%–14% in the general population, and trauma victimization (51%–98%) and PTSD (up to 42%) are even more prevalent among persons treated within public-sector mental health clinics. Despite this, individuals with PTSD and severe mental illness (SMI) who are treated within the public sector tend to receive inadequate mental health services. In addition, treatments for PTSD for this population remain undeveloped, with virtually no available empirical treatment outcome data to guide clinicians. We propose a model for a comprehensive, multicomponent cognitive-behavioral treatment program for this target population that includes elements of consumer education, anxiety management training, social skills training, exposure therapy, “homework” assignments, and long-term follow-up care. Special considerations for public-sector consumers with PTSD and SMI are addressed, as are directions for future research.

Targeting Trauma-related Interventions and Improving Outcomes for Women with Co-occurring Disorders

National attention to the effects of interpersonal trauma has led mental health systems to adopt policies on trauma-related services; however, there is a lack of clarity regarding targeting of these services. Data from the Women, Co-occurring Disorders and Violence Study (WCDVS) were reanalyzed by grouping women on their baseline PTSD and substance abuse presentation and assessing the differential response to an integrated mental health/substance abuse intervention. Treatment effects were largest for subgroups characterized by high levels of PTSD, whereas the effects for those in the low symptom group were near zero. These findings underscore the need for clinicians to conduct careful assessments of trauma-related symptoms and to target the most intensive trauma-related interventions to individuals with PTSD symptoms.

Challenges to Developing Forensic Assertive Community Treatment

Limited information currently exists about forensic assertive community treatment (FACT) and how it serves persons with mental illness involved with the criminal justice system. This study screened 28 forensic mental health programs to identify 12 FACT teams for site visits about their consumers, their interface with the criminal justice system, and implementation and sustainability challenges. Site visit findings were reviewed by an expert panel knowledgeable about the interface between assertive community treatment and the criminal justice system. Little consensus exists about a program model for FACT and several issues require more research to guide its further dissemination. FACT represents an opportunistic adaptation to growing numbers of justice-involved persons with mental illness but practice has outpaced the evidence base.

PTSD as a Mediator Between Lifetime Sexual Abuse and Substance Use Among Jail Diversion Participants

OBJECTIVE Many of the individuals with serious mental illness involved in the criminal justice system have experienced interpersonal victimization, such as sexual abuse, and have high rates of alcohol and drug use disorders. Little attention has been paid to the prevalence of posttraumatic stress disorder (PTSD) and its potential role in the substance misuse of offenders with mental illness. METHODS The study used a path analytic framework to test the hypothesis that PTSD mediates the relationship between sexual abuse and level of alcohol and drug use among individuals (N=386) with mental illness enrolled in a multisite (N=7) jail diversion project. RESULTS Sexual abuse was strongly associated with PTSD, which was in turn associated with both heavy drug use and heavy drinking. CONCLUSIONS These findings suggest that PTSD may be an important target for jail diversion programs.