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Effectiveness of Psychoeducation Intervention on Post-traumatic Stress

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  MENTAL HEALTH NURSING Effectiveness of psychoeducation intervention on post-traumatic stressdisorder and coping styles of earthquake survivors Fahriye Oflaz  PhD Assistant professor, The Chief of Psychiatric Nursing Department, Gu¨ lhane Military Medical Academy, School of Nursing,Etlik, Ankara, Turkey Sevgi Hatipog˘lu  PhD Professor, The Dean of School of Nursing, Gu¨ lhane Military Medical Academy, School of Nursing, Etlik, Ankara, Turkey Hamdullah Aydin  MD Professor, The Former Chief of Psychiatric Department, Gu¨ lhane Military Medical Academy, Etlik, Ankara, Turkey Submitted for publication: 12 September 2006Accepted for publication: 12 March 2007 Correspondence: Fahriye OflazGu ¨lhane Military Medical AcademySchool of NursingEtlik 06018AnkaraTurkeyTelephone: þ 90 312 304 39 47E-mail: foflaz@gata.edu.tr/foflaz@yahoo.com OFLAZ F, HATIPOGOFLAZ F, HATIPOG˘LU S & AYDIN H (2008)LU S & AYDIN H (2008)  Journal of Clinical Nursing   17 ,677–687 Effectiveness of psychoeducation intervention on post-traumatic stress disorder andcoping styles of earthquake survivorsAims and objectives.  The aim of the study was to examine the effectiveness of apsychoeducation intervention based on Peplau’s approach, including problem-solving compared with intervention with medication on post-traumatic stressdisorder (PTSD) symptoms and coping of earthquake survivors. Background.  Post-traumatic reactions and recovery are the result of complexinteractions among biological, personal, cultural and environmental factors. Bothpsychosocial and psychopharmacological methods have been advised to treat PTSD.The general goal of treatment is to decrease the anxiety and to support these patientsin regaining normal daily functions. Design.  The study used a pretest to posttest quasi-experimental design with threecomparison groups. Methods.  The sample of the study included 51 survivors of the Marmara Earth-quake who met diagnostic criteria for PTSD. Comparison groups were made up aspsychoeducation only, medication only and psychoeducation with medication(PEM). Six semi-structured psychoeducation sessions were conducted individually.Patients in the ‘medication only’ group did not participate in these sessions.The Clinician Administered PTSD Scale, Hamilton Depression Scale and CopingStrategies Scale were used for the measurements. Results.  There was a significant difference between the ‘PEM’ group and the‘medication only’ group with the first group showing greater relief of symptoms.Generally, there were no differences between the ‘medication only’ and ‘psycho-education only’ groups. Avoidance as a coping strategy had significant positivecorrelations with PTSD and depression outcomes.   2008 The Authors. Journal compilation    2008 Blackwell Publishing Ltd  677 doi: 10.1111/j.1365-2702.2007.02047.x  Conclusions.  Patients with PTSD seem to take more advantage from the combinedtreatment model. Nurses can help the patients with PTSD by teaching them to copewith the symptoms. Relevance to clinical practice.  The number and variety of catastrophic events in theworld are increasing. Psychiatric nurses should therefore take responsibilityregarding the effects of trauma and investigate the ways of working with peoplewho experienced trauma in more detail and develop interventions based on scientificevidence. Key words:  coping, nurses, nursing, psychiatric nursing, traumatic stress. Introduction Disastersarelarge-scaleeventsthataffectsignificantnumberof people at the same time and are beyond individual control.Among the natural disasters, earthquakes are very commonand one of the most devastating. Unlike other catastrophicevents, prediction of or preparation for earthquakes is notpossible and the adverse effects are widespread and long term.Besides the general environmental devastation, a high risk of psychological morbidity has been observed among survivors.Earthquakes have been faced frequently in Turkey and themost devastating earthquakes, measuring 7 Æ 4 and 7 Æ 2 on theRichterscale,occurredin1999.Theseearthquakeshitthemostdensely populated district in Turkey within three months. Inadditiontothepeoplewhowereaffecteddirectly,thousandsof peopleeithergotinvolvedinrescueeffortsorwitnessedpainfulexperiences during and after these earthquakes. Related tothese earthquakes, Bas  ¸ og˘lu  et al.  (2002) reported that theestimatedrateofpost-traumaticstressdisorder(PTSD)amongtheearthquakevictimswas43%justaftertheevent.Inanothersurvey, Livanou  et al.  (2002a,b) found that the rate of PTSDamong the survivors was 63% 14 months after the event andS  ¸ alc ı og˘lfu  et al.  (2003) reported that the prevalence of PTSDwas 39% among victims that had not sought treatment20 months after the earthquake in Turkey.Despite the emphasis on recognizing the magnitude of physical, emotional, social and spiritual components of traumatic experiences and numerous studies about thesymptomatology and intervention approaches in the litera-ture, there are very few studies about the psychological andsocial consequences of disasters in Turkey. The lack of knowledge and an intervention model to deal with personswith PTSD are challenges in daily clinical practice, partic-ularly in nursing. As there is an urgent need to be preparedfor large-scale disasters and deal with the extensive psycho-pathology, an increased understanding of the responses of survivors and cost-effective intervention models are stillneeded. Background Various studies on disaster victims indicate that PTSD andmajor depression are the most common psychological prob-lems resulting from earthquake (Briere & Elliot 2000, Wang et al.  2000, Chen  et al.  2001, Armenian  et al.  2002, Bourque et al.  2002, Livanou  et al.  2002a,b, Kuo  et al.  2003). PTSD isa chronic and disabling disorder associated with increasedsubstance abuse, suicidal ideations, comorbid psychiatricdisorders and physical health problems in the long term.These adverse effects of the disorder create an increasedeconomic burden for all healthcare systems and the society(Kessler 2000, Marsella  et al.  2001, Katz  et al.  2002, Chan et al.  2003). Despite the studies that investigate the treatmentmodels, there are still no studies convincingly defining long-term effects of the treatment. To date, little is known aboutthe factors related to the treatment results and how to helpindividuals with PTSD is a challenge for mental healthprofessionals.Post-traumatic psychopathology and recovery are theresult of complex interactions among biological, personal,cultural and environmental factors and the type of event(Davidson & Connor 1999, Chen  et al.  2001, Livanou  et al. 2002a,b). Both psychosocial and psychopharmacologicalapproaches have been used to help persons with PTSD andthese combined therapies are most frequently recommended.In general, the goal of treatment is to decrease the anxiety andto support these patients in regaining normal daily functions(Foa  et al.  1999, Aker 2000, Brunello  et al.  2001, Bas  ¸ og˘lu et al.  2003).Taken in this context, we believe that Peplau’s develop-mental theory will be helpful to psychiatric nurses ininterviewing individuals and constructing interventions.Peplau defines nursing as a therapeutic and interpersonalprocess and the theory is suitable for short-term individualtherapy (Ryles 1998, Birol 2000).According to Peplau, the patient’s health depends on thereduction of anxiety. In other words, good health depends F Oflaz  et al. 678    2008 The Authors. Journal compilation    2008 Blackwell Publishing Ltd  primarily on diminishing anxiety and what diminishesanxiety is communication. The patient–nurse relationshipshould be directed towards decreasing the severity of anxiety.The core of Peplau’s model is an interpersonal process and inthis relationship the nurse directs the purpose and the processitself. In the process of patient–nurse interaction, the nurseplays a role as an advisor, source, instructor, technical expert,leader and representative.According to Peplau, tension appears when individualsface stressful situations and this tension creates energy. Thisenergy is used either in a positive or negative way and healthis inter-related with the use of this energy caused by stress ina positive way. The response to stress depends on theintensity of the event and the capacity of the individual torespond. The first aim of nursing is to sustain the vitality of the organism and then help the patient understand what thehealth problem is. The nurses help the patient use thestressful situation as a learning experience to gain newbehavioural patterns. Nurses help individuals understandtheir own reactions and coping mechanisms and thereforeprotect them from illness and future recurrences (Pearson et al.  1996, Birol 2000). In this context, the concepts andprinciples explained in Peplau’s patient–nurse relationshipoverlaps PTSD treatment and psychosocial theories thatenable patients to overcome trauma. Peplau’s interactionprocess is materialized in four phases (Pearson  et al.  1996,Birol 2000). Orientation phase Both the patient and the nurse understand the complex natureof the illness that the patient has gone through. At this stage,the necessary information to define the problem is collected.The nurse has an advisory role. The nurse redefines theproblem and directs the patient’s energy away from anxiety,aiming to handle the actual problem in a more constructiveway. Identification phase This phase begins after the patient accepts that a certainrelationship developed with the nurse and the nurse plansappropriate action. This is the stage where patients expresstheir feelings and share the problem. Exploitation phase In this phase, the patient defines the service provided bythe nurse and experiences reactions directed towards thisservice. Both the patient and the nurse work towardsmutually defined targets. According to the circumstances,the nurse may play an advisory, source, technical expert orother roles. Resolution phase After the resolution of the health problem, the patient doesnot demand the assistance provided by the nurse. The patientshows independent behaviours and is hopeful and open todevelopment. This phase is where the interaction betweenindividuals ends.Peplau proposed the idea that during the orientation stageit is more important to focus on the person’s individualdevelopment rather than the disease process and thereforegive the patient an opportunity to learn from this experience.The nurse assists the patient throughout the interaction totransform the energy depending on the symptoms to prob-lem-solving energy (Pearson  et al.  1996, Birol 2000).Coping strategies of individuals have been found to berelated to the symptoms and the course of the disorder. Whena traumatic event happens, pre-event coping strategies of individuals may no longer be adequate and new skills need tobe gained. That is why it is important to help individuals tocope with the disorder and environmental adversity. In fact,the factors affecting coping strategies also affect PTSDsymptomatology (Solomon  et al.  1988, Spurrell & McFarlane1993). The first step is to help individuals with PTSD todescribe the symptoms and to reduce the adverse effects of trauma while building trust by means of therapeuticcommunication. Lazarus (1993) suggested that those whouse a problem-solving approach have a lower risk of psychopathology, less depression, less anxiety and have aninternal locus of control. He also added that problem solvingcan be counterproductive and cause chronic stress when itfails. However, Spurrell and McFarlane (1993) indicated thatusing coping strategies was associated with various kinds of psychopathology but not PTSD; they found different copingmodalities were being used in acute and chronic PTSD. Inaddition, Arata  et al.  (2000) found that PTSD was associatedwith avoidance as a coping strategy. In conclusion, there is arequirement for discovering and defining ways to overcometrauma for individuals still facing this disorder. In this study,we aimed to show the effectiveness of the nursing approach inassisting patients. Method Aim The primary purpose of this study was to compare theeffectiveness of different intervention models including psy-choeducation with medication (PEM), psychoeducation only(P) and medication only (M) in reducing symptom severityand enhancing adaptive coping strategies for persons withPTSD. Mental health nursing  Post-traumatic stress disorder and coping    2008 The Authors. Journal compilation    2008 Blackwell Publishing Ltd  679  Design and procedure The study was conducted between 1 January and 31November, 2000 at the Psychiatric Outpatient Clinic of theGu ¨lhane Military Medical Academy in Ankara. Patients wererecruited for the study five months after the earthquake.Patients came to this clinic on a daily basis as walk-ins, withscheduled appointments, or on official sick calls.All participants of this study were patients who voluntarilypresented at the psychiatric outpatient service either becauseof PTSD symptoms or other mental health concerns. Theywere the persons who had experienced the earthquake.Within the study process, those patients who had experiencedthe earthquake were assessed for PTSD by a psychiatrist andthose who met PTSD criteria were referred to the researcher.Primary physician determined the diagnosis of PTSD andwhether they needed medication or not. The researcherinformed all of the patients diagnosed with PTSD, about thestudy and assessed each patient’s eligibility for enrolment. Allpatients, whether prescribed medication or not, were asked if they were willing to participate in the psychoeducationsessions and those willing were scheduled for psychoeduca-tion. There were thus three comparison groups for the study(Fig. 1) as PEM, medication only and psychoeducation only.‘Psychoeduaction only’ group was formed by the patientswho were not prescribed medication but willing to partici-pate to psychoeducation. Following the eligibility assessmentand obtaining informed consent, patients were asked tocomplete pretest questionnaires and were given a follow-upappointment. The posttest questionnaires were given oneweek after the last psychoeducation session. The average timefor completing the questionnaires was 45 minutes.Participants who were in the ‘medication only’ group werealso asked to complete the pretest and posttest question-naires. The pretest questionnaires were administered duringthe initial visit to the psychiatric outpatient department whilethe posttest questionnaires were given seven weeks later.Participants were interviewed in a private room in theoutpatient department throughout the study. Participants It was aimed to reach all the patients diagnosed with PTSDwithin the first year following the earthquake. Therefore,duringthestudy,169patientswerediagnosedwithPTSDatthepsychiatric outpatient clinic at Gulhane Military MedicalAcademy and 68 of these fitted the study sample criteria forinclusion:(1)diagnosedasearthquake-relatedPTSD;(ii)olderthan 18 years of age; (iii) literate in Turkish; (iv) willing toparticipate in the study; (v) no other diagnosed psychoticdisorder; (vi) no recent psychological treatment (includingmedicationandpsychotherapy);(vii)nobraininjury.Excludedpatients were: those who had experienced other traumaticevents such as combat, sudden loss of a loved one, or trafficaccidents; those with co-morbid psychiatric disorders (exceptdepression);andthosewhodidnotfittheinclusioncriteria.Of the eligible 68 patients, 17 (25%) patients were not willing toreceive any treatment or psychoeducation.Signed informed consent was obtained from each partici-pant. Patients who participated in the study were militarypersonnel and their family members who were diagnosed ashaving earthquake-related PTSD, with 78 Æ 4% ( n  ¼  40) of the participants living in the epicentre of the earthquake area( _ Izmit, Go ¨lcu ¨k, Yalova, Bolu) when the earthquakeoccurred. After the first introduction interview, 21 patients(41 Æ 2%) were assigned to the psychoeducation and medica-tion group, 16 (31 Æ 3%) patients were assigned to themedication-only group and 14 (27 Æ 5%) patients to thepsychoeducation group. Structure of psychoeducation intervention Six sessions were conducted, each approximately one weekapart. The content of the psychoeducation was based onproblem-solving stages and the progress was achieved byinterviews based on Peplau’s interpersonal relationship model(Molloy 1999). The sessions were usually 60–90 minutes inlength. Posttests were administered one week after the sixthsession. PTSD diagnosis and medication determination Administration of questionnaires and assignment into groups Psychoeducation + medication Medication alone Psychoeducation alone Psychiatrist Assessment by and consentEligibility assessment Figure 1  Protocol for assignment to theintervention groups. F Oflaz  et al. 680    2008 The Authors. Journal compilation    2008 Blackwell Publishing Ltd
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