# #

Summary Table

L. Psychosocial Adjunctive Methods/Services

OBJECTIVE

Provide a therapeutic intervention that facilitates generalizing skills for coping with PTSD from clinic to home/work/community.

BACKGROUND

Patients with chronic PTSD may develop a persistent incapacitating mental illness marked by severe and intolerable symptoms; marital, social, and vocational disability; and extensive use of psychiatric and community services. These patients may sometimes benefit more from case management and psychosocial rehabilitation than from psycho-or pharmacotherapy.

RECOMMENDATIONS

  1. Consider psychosocial rehabilitation techniques once the client and clinician identify the following kind of problems associated with the diagnosis of PTSD: persistent high-risk behaviors, lack of self care/independent living skills, homelessness, interactions with a family that does not understand PTSD, socially inactive, unemployed, and encounters with barriers to various forms of treatment/rehabilitation services.
  2. Client and clinician should determine whether such problems are associated with core symptoms of PTSD and, if so, then ensure that rehabilitation techniques are used as a contextual vehicle for alleviating PTSD symptoms.
  3. Psychosocial rehabilitation should occur concurrently or shortly after a course of treatment for PTSD, since psychosocial rehabilitation is not trauma-focused.

DISCUSSION

There are seven models of psychosocial rehabilitation services that are currently recommended as an adjunct to accompany other forms of treating PTSD. None of these models have undergone randomized, controlled trials for patients with PTSD. However, all these models have been supported by surveys and studies. Positive results with other disorders (e.g., schizophrenia) provide additional support for using these techniques in the treatment of PTSD.

If psychosocial rehabilitation services are to be implemented, the client first identifies that a particular problem exists, and then the client and clinician set personal goals and adapt appropriate rehabilitation techniques/services for PTSD. When to initiate these techniques is decided by the client and individually tailored to each stage of recovery (Wang et al., 1996). Psychosocial rehabilitation techniques are contraindicated when client and clinician conclude that the problems are resolved.

Models of Psychosocial Rehabilitation Services

  1. Self-Care and Independent Living Skills Techniques
    • While social rehabilitative therapies (i.e., teaching social, coping, and life function skills) have been proven effective in chronic schizophrenic and other persistently impaired psychiatric cohorts, they have yet to be formally tested with PTSD clients. Since they appear to generalize well from clients with one mental disorder to another, it is reasonable to expect that they will also work with PTSD clients. There is clinical consensus that appropriate outcomes would be improvement in self-care, family function, independent living, social skills, and maintenance of employment.
    • Given the positive impact of independent skills training techniques for mental disorders in general (Halford et al., 1995), PTSD-centered modules should be developed and tested for effectiveness.
  2. Supported Housing
    • Forms of housing considered more effective are those in which clinical services are integrated or efforts are made by treating staff to foster community living (Goldfinger et al., 1997; Schutt & Garrett, 1992)
    • Existing literature for persons with other forms of mental illness demonstrates that case management linked to specialized clinical services is more effective than “single-room occupancy” or “warehousing” in shelters without other forms of support (Goldfinger et al., 1997).
  3. Marital/Family Skills Training
    • Marital and family treatments for trauma survivors fall into one of two general categories: systemic approaches designed to treat marital or family disruption, and supportive approaches designed to help family members offer support for an individual being treated for PTSD. These treatments are usually provided as an adjunct to other forms of treatment that are designed to directly address the PTSD symptoms.
    • A single, low-quality RCT compared the addition of family therapy to individual therapy for war veterans with PTSD (Glynn et al., 1999). It found no significant benefit to the addition of behavioral family therapy (BFT), largely due to a high dropout rate, nor did it add significantly to the treatment of PTSD with direct therapeutic exposure (DTE) (an individual psychotherapy technique).
    • There are no research studies on the effectiveness of marital/family therapy for the treatment of PTSD. However, because of trauma's unique effects on interpersonal relatedness, clinical wisdom indicates that spouses and families be included in treatment of those with PTSD. Of note, marriage counseling is typically contraindicated in cases of domestic violence, until the batterer has been successfully (individually) rehabilitated.
  4. Social Skills Training
    • Effectiveness of social skills training has been well demonstrated over many years in many RCTs but not specifically for PTSD (Dilk & Bond, 1996).
    • Effectiveness of social skills training has been demonstrated for reducing social isolation of persons with severe mental disorders (e.g., schizophrenia); similar techniques may be promising for PTSD, particularly if adapted to address antecedent conditions involved in trauma and its consequences (Rothbaum & Foa, 1996).
  5. Vocational Rehabilitation
    • Effectiveness of vocational rehabilitation techniques in treating mental disorders has been demonstrated under controlled experimental conditions (Bell & Lysaker, 1996; Bell et al., 1996; Bell et al., 1993; Bond et al., 1997) and controlled, clinical studies (Anthony et al., 1995; Drake, 1996; Lehman, 1995; Lysaker et al., 1993).
  6. Case Management
    Although case management has been shown to be useful for a range of other psychiatric disorders, there is currently no evidence available from RCTs or from systematic reviews to support or reject the use of case management for PTSD patients.
    • Among populations with histories of trauma, the assertive community treatment models have been empirically validated under controlled (but not with random assignment) conditions (Mueser et al., 1998).
    • Most of the research that empirically validates case management has been conducted among persons with severe mental disorders (Mueser et al., 1998), presumably including persons with co-occurring PTSD and other disorders.
    • Evidence suggests that outcomes are more favorable for intensive case management (well-trained clinician teaches client psychosocial rehabilitation skills in the client’s home/community) than for simple case management (clinician links client to needed services).
    • Case management has been demonstrated to reduce inpatient hospitalizations and severe symptoms, as well as to stabilize housing for formerly homeless persons; however, there is little evidence to suggest that case management improves vocational adjustment/social functioning (Mueser et al., 1998).