A
Survey of Specialised UK Traumatic Stress Services
Jelena
Jankovic Gavrilovic1,2, Patricia d`Ardenne2, Maria
Bogic1, Nicoletta Capuzzo2, Stefan
Priebe1,2
1Unit
for Social and Community Psychiatry, Queen Mary, University of London,
UK
2Institute
of Psychotrauma, East London and the City Mental Health NHS Trust,
UK
Address
for correspondence:
Stefan
Priebe, Academic Unit, Newham Centre for Mental Health, London E13 8SP, UK,
e-mail s.priebe@qmul.ac.uk
Acknowledgment:
The
authors thank members of UK Trauma Group for their participation in the
survey
Declaration
of interest
None
Abstract
AIM
AND METHOD:
The
aim of the survey was to establish the organizational structure and practice of
specialized services for posttraumatic stress in the UK. Questionnaires were
collected from 17 specialised trauma services across the UK.
RESULTS:
Specialised
trauma services use similar therapeutic programmes, but differ with respect to
the characteristics of the treated clientele and organisational features. Whilst
almost all services routinely measure outcome, some of the instruments used
vary. There is no clear association between staff resources and number of
patients treated.
CLINICAL
IMPLICATIONS:
Specialised
traumatic stress services in the UK employ evidence-based treatment methods. A
uniform protocol to measure outcome may help to establish a common UK-wide
database on outcome of specialised treatment, and facilitate a reliable
comparison between different service organisations and programmes.
Organisational features should be considered to increase the efficiency of
services.
People
suffering from trauma related mental disorders are treated within different
services in the NHS in primary, secondary and tertiary care. The provision is
still subject to local variation (National Institute of Clinical Excellence,
2004). The National Institute of Clinical Excellence
(NICE) has been developing guidelines for the management of post-traumatic
stress disorder in adults in primary, secondary and community care. A first
draft guideline has been published in summer 2004 and the expected date of
publication is March 2005. However, these guidelines will focus more on
treatment methods than the organisation of specialised
services.
The
number of specialized trauma services has increased in the last decade. These
services are - depending on the terminology - located in specialised secondary
or tertiary care. Reasons for their increase may include additional funding in
mental health care in general and a significant
influx of refugees into the UK- a population which has a higher exposure to
trauma and prevalence of Posttraumatic Stress Disorder (PTSD) than the general population (Berthold, 2000;
Howard & Hodes, 2000; Porter & Haslam,
2001).
The
aim of this survey was to (a) establish how specialised trauma services in the
UK are organised and staffed, (b) what treatment programmes they provide, (c)
how many patients they care for, and (d) how they assess treatment outcome. Such
information should complement the NICE guidelines as a basis for further service
development.
METHOD
Measures
A
postal questionnaire was designed specifically for this survey (available from
authors on request). Respondents were asked: to record mental health
professionals who work in services; type of referrals; details about the
assessment, treatment and support provided; supervision in service; and, outcome
measures used. Categories of questions and answers are summarised in table
1.
Insert
Table 1 about here
Data
collection
Specialist
trauma services included in the survey were identified through the UK Trauma
Group (UKTG) web site, which is an informal network of practitioners working
with traumatized people in the UK. The UKTG included clinicians who run larger,
multi-professional, specialist centres or research teams and who expressed a
commitment to evidence-based practice (UK Trauma Group Website).
All
specialist trauma services found on the UK Trauma Group (UKTG) web site were
contacted. Initial contacts were made via post or email, with a brief
explanation of the aims of the survey and an invitation to complete a short
postal questionnaire. If no responses were received, further contact was made
via telephone or personally.
Out
of 23 services contacted from the list, five replied that the survey was
non-applicable to them, e.g. because they regarded themselves as a secondary
mental health service with a special interest in trauma but not as a specific
trauma service. One service reported that such information was confidential.
Hence, 17 responses were received and included in the analysis.
RESULTS
The
size of catchment areas varied from 300,000 to one million population. Four
services classified themselves as operating nationwide.
Services
vary considerably in the number of staff employed. On average, they employed 1.2
full time and 5.4 part time staff. However, there is considerable variance as
indicated by standard deviations of 1.8 for full time and 4.2 for part time
staff.
With
respect to the professional background of staff, 15 services had one or more
clinical psychologists, 12 had at least one psychiatrist in the team. All teams
had either a clinical psychologist or a psychiatrist or both. Seven services
employed nurses, five a counsellor, four services a social worker, two a
bi-cultural therapist and none employed an occupational
therapist.
Under
category of `other`, staff included speech and language therapists, behavioural
therapists, clinical psychology trainees, and a senior teacher.
Referral
pathways included five services which accept self referrals, 13 services from
primary care, and 15 from secondary or tertiary care.
The
numbers of patients seen in the year prior to the survey varied from 17 to 200.
Four services had fewer than 50 patients, five between
50 and 100, five between 100 and 150 and two services had more than 150 patients
(data for one service is missing). New referrals in the previous year vary
between 25 and 260 in these services. Yet, a significant percentage seems to
have been seen as inappropriate and, therefore, not seen. However, the survey
did not ascertain how many were inappropriate or
why.
Waiting
times were between 2 and 28 weeks and on average 11 weeks. All but one service
had separate assessment and treatment services. The average number of treatment
sessions is 12 (SD = 5). However, most centres indicated that the number of
sessions could vary significantly, and that they do not have exact figures on
how many sessions over what period of time are provided on average.
In
four services fewer than 10% of referrals were refugees. In seven
services the proportion was between 10-50% and in six services more than 50%. The most
common countries of origins were Iraq, former Yugoslavia, Iran, Afghanistan, Sri
Lanka, Sierra Leone, Somalia, and Turkey.
Most
services were designated for adults aged between 18 and 65 years. Only one
service provided for children (95% of patients under 18), and two services had more than 5% of patients over 65 years.
In
terms of therapeutic methods, 16 services provided cognitive behavioural
techniques. the components of which included relaxation and breathing controlled
techniques, cognitive restructuring,
psychoeducation about trauma, in vivo exposure to feared stimuli and
imaginal exposure to traumatic
memories. In addition, 13 services reported the use of Eye Movement
Desensitization and Reprocessing (EMDR). Only four services offered
psychodynamic techniques.
All
services provided individual psychotherapy. Six also provided
group therapy, and eight couple or family therapy. The model
referred for each of these treatments was not
specified.
All
services provided internal supervision which includes peer supervision. Four
services had regular external supervision.
Three
services provided social support, and one service vocational training. Eleven
services had a policy to provide medico-legal reports for their patients,
Fifteen
of the 17 services routinely measured
treatment outcome.
Every centre had different protocols. Four centres used structured clinical
interviews to diagnose PTSD, (Clinician Administered PTSD Scale – CAPS;
Structured Clinical Interview Schedule – SCID). Self report measures for PTSD including
the Impact of Event Scale (IES/IES-R) by 12 centres and the Posttraumatic
Diagnostic Scale by six centres.
Mood questionnaires included: the Beck Depression Inventory (BDI/BDI-II)
used by 11 centres;; the Beck Anxiety Inventory (BIA) by five centre and
Hamilton Depression Rating Scale (HADS) by two centres, General Health
Questionnaire (GHQ), the Core Assessment Outcome Package for the Care Programme
Approach (CORE) by four centres each.
;
Attempts
to cluster centres based on the percentage of refugee referrals, referral
pathways, number of patients seen, and other variables as assessed in this
survey did not reveal any meaningful grouping, and thus further statistical
comparison between centres was not conducted.
Finally,
we tested the association between number of staff (using an estimate of 0.5 full
time for each part time staff member). Non-parametric Spearman’s correlations
revealed a significant positive association between the number of patients seen
and the number of psychiatrists in the team (rs
=.659, p<.01). However, neither the number of clinical psychologists
(rs
=-.292, p>.05) nor the total number of staff (rs
=.197, p>.05) was significantly linked with the number of patients seen.
DISCUSSION
The
survey shows that most specialized trauma services across the UK have several
common features, most prominently fairly short therapeutic programmes involving
cognitive-behavioural techniques including psychoeducation and EMDR. These
methods have shown to be effective in the treatment of PTSD (Sherman, 1998; Van
Etten & Taylor, 1998) and are recommended by the NICE
guidelines.
The
range of professionals employed in the teams varies and might reflect the
importance of multidisciplinary working in the treatment of patients suffering
from posttraumatic stress syndromes. Yet, it is surprising that some teams work
without either a psychiatrist or a clinical psychologist, whose expertise seem
essential for such services.
Most
services routinely assess outcome, although they do not necessarily use the same
instruments. Whilst local ownership
and specific interests may be good reasons for using different measures, a
uniform protocol with at least one or two instruments used by all centres would
clearly be an advantage for treatment outcome evaluation. For instance, a
protocol could be the basis to establish a common UK-wide database on outcome of
specialised treatment, and facilitate a reliable comparison between different
service organisations and programmes. Thus, it might be possible to benchmark
expected outcomes and identify influential factors. For example, it would be
interesting to see whether a clientele with a higher proportion of refugees is
likely to have a less favourable outcome or not, and to what extent this depends
on features of the provided programme. What a uniform protocol cannot overcome,
however, are the difficulties to obtain complete data sets of outcome
assessments in routine treatment of an often mobile and challenging clientele
(d`Ardenne et al, in press).
Most
centres provide medico-legal reports in support of their clients which is a
controversial issue. The potential or actual provision of such reports can
arguably impact on the therapeutic alliance between client and clinician and
changing treatment outcome. Collaboration between centres should be considered
as a means of preventing clinicians from taking an incompatible role of
therapist and impartial expert. Teams
that have larger numbers of psychiatrist tend to see more
patients. However, there was no significant association between more total staff
and number of patients seen. Although this may have been partly due to the small
sample size in the statistical analysis, this negative finding suggests that
some services might increase efficiency, in terms of seeing more patients with
the same resources, through organisational change. Alternatively, smaller
services may be more flexible or have other advantages that enable them to see
more patients with fewer resources. In
conclusion, the publication of NICE guidelines on treatment of PTSD will prompt
services to comply with evidence-based practice. Specialized services already
appear to employ such methods, but may have to develop even more harmonised
practice according to the guidelines. Yet, the guidelines do not cover the
organisation of specialised services and the routine measurement of outcome. The
survey shows that services can improve on both aspects, and stronger
collaboration will probably be helpful. REFERENCES Berthold,
S.M. (2000).
War traumas and community violence: Psychological, behavioral and academic
outcomes among Khmer refugee adolescents. Journal of
Multicultural Social Work, 8,
15-46. d’Ardenne,
P., Capuzzo, N., Fakhoury, F.,
Jankovic-Gavrilovic J., & Priebe S. (2004).
Subjective Quality Of Life and Posttraumatic Stress Disorder. Journal of Nervous and Mental Disease, in
press. Howard,
M. R. & Hodes, M. (2000).
Psychopathology, adversity and service utilization of young refugees. Journal of
the American Academy of Child and Adolescent Psychiatry, 39,
368-377. Porter,
M., & Haslam, N. (2001).
Forced displacement in Yugoslavia: A meta-analysis of psychological consequences
and their moderators. Journal of Traumatic Stress, 14,
817–834. Sherman,
J. L. (1998).
Effects of psychotherapeutic treatments for PTSD: a meta-analysis of controlled
clinical trials. Journal of Traumatic Stress, 11,
413–435. Van
Etten, M. L & Taylor, S. (1998).
Comparative efficacy of treatments for post-traumatic stress disorder: a
meta-analysis. Clinical Psychology and Psychotherapy,
5,
126–144. National
Institute of Clinical Excellence (2004).
Posttraumatic Stress Disorder (PTSD)
Clinical Guidelines. UK. http://www.nice.org.uk/page.aspx?o=57890. UK
Trauma Group Website (2004).
UK Services. UK.
http://www.uktrauma.org.uk/ukservcs.html Table
1. Information collected by Traumatic Stress Services
Survey Profile
of professionals
- psychiatrists, clinical psychologists, counsellors, occupational
therapists, social workers, nurses, bi-cultural
workers Type
of referrals
- self-referral, primary, secondary, tertiary services or other referrals;
number of referred and number of seen patients; average waiting time for
the first appointment Number
of patients refereed and seen in a year prior to carrying out a
survey Treatment
sessions
– waiting time, separate assessment and treatment session, average number
of sessions and range of sessions of complete
treatment Refugees
- percentage of overall referrals, most frequent countries of origin,
interpreting services needed Patients
age groups
- under 18, 18-40, 40-65, over 65 Treatment
methods
- psycho-education, revisiting/re-exposure, behavioural techniques,
cognitive techniques, psychodynamic techniques, relaxation,
EMDR Support
- medico legal, social support, vocational
training Type
of therapy – individual,
group, couple and family therapy Type
of supervision
- peer, internal, external Type
of outcome measures for treatment effectiveness