CLINICAL HANDBOOK OF SCHIZOPHRENIA

43. Trauma and Posttraumatic Stress Syndromes 455with these treatment models has included some (but not necessarily a majority) of clientswith schizophrenia. Assessment of the treatment models has involved either openor randomized clinical trials of varying levels of rigor (e.g., uniform implementation;good characterization of clients served; use of well-validated, standard outcome measures).Like trauma and PTSD treatments designed for the general population, these interventionshave relied on a relatively small set of therapeutic ingredients, often combiningwith or employing somewhat different mixes and emphases. Common therapeutic elementsinclude psychoeducation, stress management techniques, teaching strategies andresources to enhance personal safety, prolonged exposure to trauma-related stimuli (e.g.,memories, safe but fear-eliciting situations), cognitive restructuring, group support, skillstraining, and empowerment. Of these elements, the empirical literature on PTSD treatmentin the general population has shown that prolonged exposure and cognitive restructuringare the most effective treatments. Interventions designed for more vulnerable populations,including those with psychotic disorders, have used both group and individualformats (with some models combining the two), and intervention length has ranged from12 weeks to 1 year or more. Some models have been developed specifically for women,particularly women survivors of sexual abuse, whereas other, more general models are forall types of trauma exposure (in either childhood or adulthood) leading to PTSD. Severalmodels focus on PTSD per se, whereas others attempt to address a broader array of problemsassociated with chronic victimization. These models, and the level of evidence supportingthem, are summarized in Table 43.1.TREATMENT GUIDELINES1. All clients with schizophrenia spectrum disorders should be assessed with standardizedinstruments for trauma exposure and for PTSD.2. Providers working with these clients should be trained to understand posttraumaticstress syndromes, and to recognize their symptom presentation in schizophrenia.3. Services for such clients should be trauma-aware (e.g., housing recommendations;gender of providers; guidelines for use of restraints for abused clients that factor intrauma-related issues).4. Clients should receive psychoeducation about trauma and posttraumatic stresssyndromes, including how to recognize PTSD symptoms, how PTSD might exacerbatepsychotic illness, and what treatments might be available.5. Trauma-specific treatments (with different levels of empirical support) are availableand well described in the literature. Service systems that provide care for clients withschizophrenia should choose trauma interventions best suited for their clients and settings,and train staff in providing these treatments.6. Providers should learn who in their area is able to provide trauma-specific treatmentsfor clients with both schizophrenia and PTSD symptoms.7. Given the high level of ongoing trauma in clients with schizophrenia, periodic reassessmentfor trauma exposure and PTSD should be part of standard care.8. PTSD symptoms can persist over many years, and symptoms ebb and wane, oftenin response to external stressors. Providers should be aware that clients’ PTSD mayreemerge, and follow-up treatments or “booster” sessions may be required when clientsundergo stress.