Community Ment Health J (2015) 51:663–673 DOI 10.1007/s10597-015-9887-z

ORIGINAL PAPER

Coping Styles Among Individuals with Severe Mental Illness and Comorbid PTSD Shannon A. McNeill1,2 • Tara E. Galovski2

Received: 13 December 2013 / Accepted: 6 May 2015 / Published online: 5 June 2015 Ó Springer Science+Business Media New York 2015

Abstract There is little known about coping styles used by individuals with severe mental illness (SMI) and even less known about the influence of a comorbid posttraumatic stress disorder (SMI-PTSD) diagnosis on coping. The current study examines differences in utilization of coping strategies, overall psychological distress, and exposure to traumatic events between SMI only and SMI-PTSD individuals seeking community mental health clinic services (N = 90). Results demonstrate that overall psychological distress and use of avoidance coping were significantly higher among the SMI-PTSD sample. Avoidance coping partially mediated the relationship between PTSD symptom severity and psychological distress. Findings suggest that the experience of PTSD for those with SMI is associated with increases in avoidance coping, a coping style that significantly contributes to psychological distress. Implications for further study and treatment within community mental health clinics are considered. Keywords Coping
Trauma
Posttraumatic stress disorder
Avoidance
Severe mental illness

& Shannon A. McNeill [email protected] 1

Department of Psychology, University of Missouri - St. Louis, One University Blvd, St. Louis, MO 63121, USA

2

Department of Veterans Affairs, VA Boston Healthcare System, 940 Belmont St, Brockton, MA 02301, USA

Introduction By definition, individuals with severe mental illness (SMI), such as schizophrenia, schizoaffective disorder, and bipolar disorder, experience marked distress and significant limitations across multiple life domains, such as social and occupational functioning, ability to engage in leisure activities, and in elements of self-care (Mueser et al. 2004; National Alliance on Mental Illness 2011; Peck and Scheffler 2002). Those with SMI also frequently experience criminal victimization (Hiday et al. 1999; Subica et al. 2012). In fact, victimization and exposure to other traumatic events are experienced at a much higher rate than the general population thus increasing the likelihood of the subsequent development of posttraumatic stress disorder (PTSD) (Cusack et al. 2006; Lommen and Restifo 2009). PTSD is a disorder marked by intrusive and impairing reexperiencing, avoidance, and hyperarousal symptoms that persist after exposure to a serious traumatic event (American Psychiatric Association 2000). Although awareness of the prevalence of comorbid PTSD among those with SMI is increasing, less is known about the influence of this additional disorder on overall psychological distress and the coping strategies used to mitigate such distress (Grubaugh et al. 2011; Mueser et al. 2002). The current literature on psychosocial functioning and psychopathology suggests that those suffering from SMI manage a range of stressful psychosocial issues such as financial difficulties, limited social networks, and criminal victimization (Macdonald et al. 1998; Shelton et al. 2009; Teplin et al. 2005). Individuals with SMI report increased stress and perceived personal inefficacy as compared to healthy controls along a range of psychological and social domains (Betensky et al. 2008). The addition of a diagnosis of PTSD may further complicate an already complex SMI

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diagnostic presentation. Mueser et al. (2002) propose an interactive model of how PTSD mediates SMI symptom severity and the need for acute care. Among the likely processes described in this model, the researchers explain that PTSD can have a profound negative impact by exacerbating psychological distress and impairing one’s ability to effectively cope with additional stress. Supporting this model, recent study demonstrates that the addition of PTSD symptoms among those with SMI results in poorer mental health functioning and increased depression (Subica et al. 2012). Additionally, those with SMI and comorbid PTSD (SMI-PTSD) are at greater risk to engage in life-endangering behaviors following stressful events, and are more likely to attempt suicide than those with SMI alone (Alvarez et al. 2012; O’Hare et al. 2006). Thus it appears that the combination of SMI and PTSD portends particularly poor outcomes. Mueser and colleagues’ (2002) model suggests that the addition of PTSD may further impair adaptive coping in those with SMI, such that individuals with SMI-PTSD may employ different coping strategies with deleterious effect. To date, there is little known about the utilization of coping strategies in the SMI population and virtually nothing is known about the influence of an additional PTSD diagnosis on coping. Review of the current literature on SMI and coping indicates that two primary coping strategies are most often utilized: avoidance and problem-focused coping (Phillips et al. 2009; Yanos et al. 2010). Avoidance coping is described as a set of behavioral and cognitive responses to stress aimed at reducing the experience of anxiety by avoiding it (Lazarus and Folkman 1984; Pineles et al. 2011). Avoidance coping strategies can include abusing substances, social withdrawal, or intentionally focusing one’s attentions away from the perceived source of the anxiety (Lazarus and Folkman 1984; Yanos et al. 2003). Persons with SMI who use avoidance coping strategies to deal with stressful events experience more negative mood, decreased productive use of time (e.g. increased time spent sleeping, watching TV), increased residual distress following natural disasters, increased schizophrenia symptoms, and heightened neuroticism trait levels (Horan et al. 2007; Lysaker et al. 2003; Meyer 2001; Yanos et al. 2010). Problem-focused coping describes a person’s use of specific strategies aimed at reducing distress by resolving or changing the objective variables of a situation. Individuals may use behavioral or cognitive problem-solving skills, such as using social supports, evaluating one’s options, making a decision, and acting upon the chosen decision (Sabina and Tindale 2008). The proactive nature of this strategy indicates that it is generally considered a positive or adaptive coping strategy, particularly when the stressor is believed to be changeable (Holahan et al. 1996). Among persons with SMI, problem-focused coping strategies, such as the use of

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prescribed medication and social supports, have been associated with decreased negative mood and better social functioning (Yanos et al. 2003, 2010). Findings from the extant literature on coping and SMI provides insight into how this population manages the many stressors they experience; however, the experience of PTSD among the SMI samples is not addressed. PTSD has been conceptualized as a catalyst for symptom exacerbation and prognostically poorer outcomes for those with SMI (Mueser et al. 2002; Vogel et al. 2006). Without identifying the presence of this disorder among individuals with SMI, we are limited in determining how PTSD influences coping. Furthermore, avoidance is an integral part of the PTSD diagnostic picture, though it is unclear how influential avoidance coping is in the relationship between PTSD symptom severity and psychological distress for those with SMI. Investigation into the use of coping strategies in this sample may identify areas of both strengths and weaknesses in managing symptoms and engaging in treatments for those who suffer from these significant mental disorders. The current study investigates specific coping strategies utilized by individuals with SMI, while also exploring group differences in coping associated with the comorbid diagnosis of PTSD. The first aim of the current study was to directly compare those with SMI and no additional PTSD diagnosis (SMI), with a sample of individuals with SMI and a comorbid diagnosis of PTSD (SMI-PTSD) on measures of psychological distress and coping. It was hypothesized that between-group differences would emerge such that the SMI-PTSD sample would report more psychological distress and avoidance coping use. Additionally, it was hypothesized that the SMI group would report more problem-focused coping use. The second aim of the study was to investigate the role of avoidance coping in the relationship between PTSD symptom severity and psychological distress for those who have experienced a traumatic event. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision’s (DSMIV-TR; American Psychiatric Association 2000) specification of ‘Criterion A’ traumatic event was used to define traumatic event (as opposed to significant life stressor). It was hypothesized that for individuals who have experienced a trauma, regardless of whether they met criteria for PTSD, PTSD symptom severity would predict overall psychological distress indirectly through avoidance coping.

Methods Participants Ninety male (58 %) and females over the age of 18 years (M = 40 years) participated in the study. Participants were

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most often African American (72 %), graduated from high school or otherwise passed a General Educational Development test (35 %), identified their relationship status as single (82 %) and were currently unemployed (97 %). Eligible participants for the SMI group (n = 42) included individuals with a current SMI (includes schizophrenia, schizoaffective, schizotypal or schizoid personality disorder, psychotic disorder not otherwise specified, delusional disorder, bipolar I, and/or MDD that met ‘‘severe’’ status) but no PTSD. The SMI-PTSD group (n = 48) included participants meeting criteria for a current SMI, as well as PTSD. Procedures Recruitment All participants were recruited through a community mental health clinic (CMHC) based in a Midwestern major metropolitan setting serving individuals at-risk for, or currently experiencing, homelessness, SMI and/or substance use disorders. The IRB-approved procedures for approaching individuals for participation dictated that recruitment and consenting were to be conducted only after the Mini Mental State Exam (MMSE; Folstein et al. 1975) and diagnostic interview portion of the assessment were completed. The MMSE was used to determine competency to consent, while current SMI status was confirmed with the Structured Clinical Interview for DSM-IV Axis I and II Disorders (SCID-I and II: First et al. 1996; First et al. 1997). This procedure was done to (1) assuage potential frustration for ineligible persons completing the assessment with hopes of study participation, and (2) to reduce the potential for false reporting during the diagnostic assessment—either due to individuals’ desire to be seen as eligible or ineligible study participants. As a result, individuals who did not meet minimum MMSE criteria to determine competency to consent or diagnostic criteria were not approached for study participation. These procedures for identifying potentially eligible study participants were not used to restrict or promote mental health services for individuals at the site of recruitment.

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Eighty-five of the ninety participants completed studyrelated measures, including the MMSE and diagnostic assessments with the principal investigator, an advanced graduate student with more than five years of experience with DSM-IV diagnostic assessment and use of the SCID-I. The remaining five participants were assessed by a research assistant with significant clinical experience. The research assistant received training by the principal investigator on the diagnostic instruments and participated in clinical supervision of his diagnostic work by a licensed clinical psychologist. Reliability of diagnostic outcomes was not evaluated using traditional research methods, such as interrater analysis. However, typical clinical methods of verifying diagnostic outcomes for each participant were conducted, such as records reviews for previous diagnoses when available and consultation with licensed clinical psychologists and psychiatrists after diagnostic assessment was completed. All data collection, analysis, and maintenance procedures were reviewed and approved by University and CMHC Institutional Review Boards. The authors of this investigation and publication have no known conflicts of interest to disclose and certify responsibility of this manuscript. Measures Mini Mental State Exam The Mini Mental State Exam (MMSE; Folstein et al. 1975) is a brief screening tool for cognitive impairment. It contains tasks that evaluate eight domains of cognitive functioning including orientation to time, orientation to place, registration, attention and calculation, recall, language, repetition, and complex commands. Out of a possible 30 points, scores B25 are considered non-normative and mental capacity may be compromised. This cut-off was used in the present study to determine capacity to consent. The MMSE has been found to appropriately predict capacity to consent to research participation, power of attorney, and placement in residential care (Whelan et al. 2009). Demographics

Data Collection Interested participants provided retrospective consent to use diagnostic data collected during their diagnostic assessment and MMSE testing, while prospective consent was secured to use subsequent data collected for the purpose of the current study. As compensation for their completion of the study, participants were provided with $10 cash.

Basic demographic information, including age, race, sex, education, etc. was collected using a measure generated for the purposes of the current study. Structured Clinical Interview for DSM-IV Axis I Disorders The SCID-I (First et al. 1996) is a semi-structured clinician-administered measure used to assess the presence of

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Axis I disorders. The following modules were administered to generate diagnostic profiles of the participants: mood, anxiety, psychotic, and substance disorders. Structured Clinical Interview for DSM-IV Axis II Personality Disorders The SCID-II (First et al. 1997) is a semi-structured clinician-administered tool used to diagnose DSM-IV Axis II personality disorders. Reliability tests of the SCID-II for DSM-IV indicate that the measure has moderate to high kappa levels between raters (k = .65–.97) (Lobbestael et al. 2011). Brief-COPE The Brief-COPE (Carver 1997) is a 28-item self-report measure adapted from the COPE, the original full-length coping measure (Carver et al. 1989). The items are formatted in a 4-point likert scale rating system that describes the frequency of coping strategy use. Three aggregate subscales, originally generated and used by Schnider et al. (2007), evidence strong alpha coefficient ratings (problemfocused = .80, active-emotional = .81, avoidant-emotional = .88). The Brief-COPE has been applied to many different populations and instruction sets vary from asking participants to focus on a specific event to stressful events more generally (Krageloh 2011). For the purposes of the current study, participants were asked to describe and focus on a particularly stressful event they have experienced in the past month and answer the items based on how they coped with it. Orienting participants to a specific personal events helped to accurately report on the coping methods they used. For the current study, only the avoidance and problem-focused coping subscales were used in analyses. These subscales demonstrated acceptable internal consistency ratings (a = .73 and .82, respectively). PTSD Checklist-Specific The PTSD Checklist-Specific (PCL-S: Weathers et al. 1993) is a 17-item self-report measure that assesses the presence and symptom severity of PTSD based on the exposure to a specific traumatic event. Symptom severity is assessed using a 5-point likert rating (1 = not at all to 5 = extremely). Summation of the scored items generates a total severity score, which can range from 17 to 85. A total symptom severity cut-off score of 44, along with confirmation of required minimum symptom presence for PTSD diagnostic criteria is recommended to achieve optimal sensitivity and specificity of the PTSD diagnosis (Blanchard et al. 1996; Ruggiero et al. 2003). The PCL-S has been used and validated with SMI samples (Cusack

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et al. 2006; Mueser et al. 1998, 2001). Mueser et al. (2001) used the measure with an SMI sample and reported finding strong internal consistency for the total severity score (a = .94), moderate reliability rates through test–retest comparisons (r = .60 and 80 % agreement), as well as moderate convergent validity with other measures of PTSD (r = .67 and 83 % agreement). For the current study the PCL-S total severity score was used in analyses. The measure demonstrated a strong internal consistency rating (a = .95). Brief Symptom Inventory The Brief Symptom Inventory (Derogatis 1975) is a widely used self-report measure of psychological distress. Fiftythree items are rated on a 5-point likert scale (0 = not at all to 4 = extremely) to generate nine subscales of distress and three total indices of symptom presence and distress. Psychometric evaluations of the BSI indicate that its subscales have good internal consistency (alphas ranging from .71 to .85) and the global severity index has good test– retest values (.90). The validity of the BSI is excellent, as it demonstrates good convergent and divergent properties (Derogatis and Melisaratos 1983). The BSI has proven to be a good measure of psychological distress among SMI populations and across ethnicities (Hoe and Brekke 2008). The current study used the global severity index to report on overall psychological distress of the collected sample. These subscale demonstrated acceptable ranges of internal consistency ratings (a = .80–.98). Analytic Plan Study group differences in overall psychological distress were tested using an independent samples T test. Coping style differences between groups were examined using multivariate analysis of variance (MANOVA). The two study groups (SMI and SMI-PTSD) differed significantly on the proportion of primary SMI diagnoses (specifically, MDD and schizophrenia) represented in each group. Further examination of these differences are detailed in the results section below. In an effort to explore these diagnostic differences without diluting the genuine impact of diagnostic status on dependent variables of interest, additional analyses were conducted with diagnosis and study group interaction terms included. Baron and Kenny’s (1986) statistical model was used to test the mediational impact of avoidance coping on the relationship between PTSD symptom severity and psychological distress. Only participants who endorsed a ‘Criterion A’ trauma were included in these analyses (n = 75). A Sobel Test was applied to elicit the significance of any detected indirect effects (Preacher and Hayes

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2004). In an effort to assure that all statistical procedures were appropriate for the type and scope of data collected, assumptions for the specific tests were examined. Power Analysis A priori power analyses for each of the tests of hypotheses were conducted to determine minimum sample size for the current investigation. Results demonstrated that to achieve appropriate power (80 %) to detect a medium effect (f2 = .25) at the .05 level, a minimum of 68 participants were needed for the most complex analysis (multiple regression to determine mediation).

Results The overall sample’s mean scores for psychological distress (M = 2.06, SD = 1.07) and PTSD symptom severity (M = 52.59, SD = 18.98) were above the clinical severity cutoffs. Overall mean avoidance coping scores (M = 24.41, SD = 6.30) were slightly higher than problem-focused coping (M = 23.16, SD = 5.62), though T-tests did not indicate a significant difference between the subscales, t(89) = 1.42, p = .16. In terms of trauma exposure, 83 % of the total sample reported experiencing a ‘Criterion A’ traumatic event. The average number of unique traumas experienced by participants during their lifetime was 3.7 (SD = 2.20) and PTSD was the most frequently diagnosed comorbid disorder. Full demographic descriptives for the individual study groups are represented in Table 1. No demographic variables differed significantly across study groups. Specific Axis I disorders qualifying participants for an SMI were compared across study groups. Results are displayed in Table 2. The study groups differed significantly based on the proportion of SMI primary disorders identified in each group, v2 (8) = 33.91, p \ .05. Since these are not randomized conditions, this significant difference in SMI diagnosis may be related to the group assignment process (presence of PTSD or not), but that is beyond the scope of the study. Separate regression analyses predicting the variance of coping, psychological distress, and posttraumatic stress symptoms accounted for by primary diagnosis indicated significant contribution of the predictors. As such, diagnostic status is proportionally disparate between study groups and has a predictive impact on dependent variables used study analyses. To further explore the contributions of diagnostic status on key variables, interaction terms between diagnosis and study group were included in subsequent analyses. In an analysis of study group differences on reported psychological distress, results indicated that overall

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psychological distress, as measured by the BSI, was significantly greater among the SMI-PTSD group (M = 2.64, SD = .83) as compared to the SMI group (M = 1.40, SD = .92), t(88) = -6.76, p \ .05, Cohen’s d = 1.42. Results of the MANOVA, testing for group differences on avoidance and problem-focused coping, indicated that an overall effect was present between the SMI and SMI-PTSD groups on variables of coping, Pillai’s Trace V = .23, F(2, 87) = 12.80, p \ .05, partial g2 = .23. Follow-up ANOVAs were performed to detect specific group differences. Results indicated that avoidance coping was significantly greater among the SMI-PTSD group as compared to the SMI group, F(1, 88) = 25.49, p \ .05, partial g2 = .23. Alternatively, the groups did not differ on problem-focused coping. Results from these analyses are detailed in Table 3. A follow-up MANOVA with diagnostic and study group interaction terms included was conducted to observe main effect group differences (SMI vs. SMI-PTSD) on avoidance and problem-focused coping while accounting for variance attributable to diagnostic status within groups. Results of this follow-up test of omnibus effects upheld the original MANOVA findings, demonstrating that significant difference continued to be observed between the SMI and SMI-PTSD groups on measures of coping, Pillai’s Trace V = .25, F(2, 85) = 14.15, p \ .05, partial g2 = .25. Follow-up ANOVAs were performed to detect specific group differences. Results indicated that avoidance coping, as measured by the Brief-COPE, was significantly greater among the SMI-PTSD group as compared to the SMI group, F(1, 86) = 28.51, p \ .05, partial g2 = .25. Again, no significant group differences were observed for problem-focused coping. In testing the mediation model of avoidance coping on the relationship between PTSD symptom severity and psychological distress four analyses were performed on data from participants who reported ‘Criterion A’ trauma exposure (n = 75). First, PTSD symptom severity significantly predicted psychological distress, F(1, 74) = 125.09 p \ .05, R2 = .63. Likewise, PTSD symptom severity significantly predicted avoidance coping, F(1, 74) = 27.86 p \ .05, R2 = .27 and avoidance coping significantly predicted psychological distress while controlling for PTSD symptom severity F(1, 74) = 42.11 p \ .05, R2 = .37. Results of the fourth regression were used to evaluate the overall mediational model. The findings demonstrated a reduction in the b coefficient for this final model, but the prediction of PTSD symptom severity on psychological distress remained significant, F(2, 74) = 76.46, p \ .05, R2 = .68. This reduced, but still significant, b coefficient indicated a partial mediation. Finally, results from the Sobel Test confirmed that the partial mediational effect was significant, Z = 2.76, p \ .05. Intercorrelations and regression summaries are detailed in Tables 4 and 5.

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668 Table 1 Demographic characteristics of participants (N = 90)

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Characteristic

SMI (n = 42)

SMI-PTSD (n = 48)

n

%

n

%

Male

31

74

21

44

Female

11

26

27

56

34

81

31

65

Caucasian

8

19

15

31

Bi-racial (AA and Asian)

0

0

2

4

Race African American

Housing Outdoors/shelter

15

36

22

46

Own or other’s home

22

52

23

48

5

12

3

6

Hotel, boarding, halfway house Highest education level completed 0–8th grade

3

8

6

14

9–11th grade

12

33

13

30

High school or GED

13

35

15

34

Some or graduated college

8

19

9

19

Graduate school

1

2

1

2 77

Marital status Single

37

88

37

Married

0

0

2

4

Divorced/separated/widowed

5

12

9

19

32

82

36

84

6

15

9

19

22

52

30

63

Accidents (car, sport injury, etc.)

23

55

27

56

Domestic violence

15

36

35

73

Criminal victimization (robbery, mugging, etc.) Childhood sexual abuse

15 10

36 24

26 30

54 63

Childhood physical abuse

11

26

28

58

Legal problems (ever) On probation at time of survey Alcohol or drug use in past year Trauma exposure

Totals of percentages are not 100 for every characteristic because of rounding

Separate regression analyses were performed to include diagnostic status and study group main effect and interaction terms within each of the four mediational model regressions described above. Inclusion of these variables did not significantly change the model’s predictive ability for the outcome variables (psychological distress, avoidance coping, and PTSD symptom severity).

Discussion The current study investigated coping strategy utilization by SMI individuals, with and without comorbid PTSD seeking services at a metro-area CMHC. Participants (N = 90) were demographically similar to previous studies in their reports of significant struggles across numerous domains of functioning including finances, employment,

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education, legal issues, and interpersonal relationships (Clark et al. 1999; Ford 2012; Hiday et al. 1999; Macdonald et al. 1998; Shelton et al. 2009). This study contributes to the literature by assessing the high rate of trauma exposure and resultant PTSD within a community-based sample of persons struggling with SMI. An overwhelming majority of the total sample reported experiencing a ‘Criterion A’ traumatic event during their lifetime and PTSD was the most common Axis I condition diagnosed. The average number of unique traumas experienced was 3.7, with the most often reported traumas including domestic violence, serious accidents, and criminal victimizations. The rate of trauma exposure within the current SMI sample (83 %) far exceeds those reported estimates of the general population, which range from 39 to 56 % (Breslau et al. 1991; Kessler et al. 1995). Our findings support the accumulating evidence that SMI

Community Ment Health J (2015) 51:663–673 Table 2 Diagnostic status at the time of survey between groups

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Diagnosis

SMI (n = 42) n

SMI-PTSD (n = 48) %

n

%

Major depressive disorder*

9

21

24

50

Bipolar I disorder

5

12

9

19

Dysthymic disorder

1

2

2

4

Depressive disorder NOS

1

2

0

0

Schizophrenia*

22

52

2

4

Schizoaffective

5

12

11

23

Delusional disorder

1

2

1

2

Psychotic disorder NOS

1

2

3

6

Alcohol abuse or dependence*

11

26

23

48

Drug abuse or dependence

17

40

31

65

Panic disorder w/out agoraphobia* Social phobia

4 7

10 17

22 12

46 25

Specific phobia

1

2

3

6

Obsessive–compulsive disorder

0

0

4

8

Generalized anxiety disorder

0

0

2

4

Schizoid personality disorder

1

2

0

0

Schizotypal personality disorder

1

2

0

0

Borderline personality disorder

3

7

6

13

Antisocial personality disorder

3

7

1

2

Depression spectrum disorder*

12

29

33

69

Psychotic spectrum disorder*

30

71

15

31

* Significant differences between groups (SMI vs. SMI-PTSD) observed at p \ .05

Table 3 Means and multivariate analysis of variance results for coping strategies as a function of group

Coping strategy

SMI M

SMI-PTSD SD

M

SD

F(1, 88)

p

Partial g2

Brief-COPE Avoidance

21.24

6.30

27.19

4.86

25.49

\.00

.23

Problem-focused

22.80

5.80

23.46

5.50

.30

.59

\.00

Table 4 Means, standard deviations, and intercorrelations for psychological distress predictor variables among trauma exposed participants (n = 75) Variable

M

Psychological distress Predictor variable 1. PTSD symptom severity a

2. Avoidance coping

SD

2.24

1.00

55.71

17.74

24.77

5.96

1

2

.79***

.60***

–

.53*** –

*** p \ .001 a

Avoidance coping measured by Brief-COPE subscale

populations experience high rates of exposure to traumatic events and PTSD prevalence (Cusack et al. 2006; Gearon et al. 2003; Lommen and Restifo 2009; Mueser et al. 1998; Subica et al. 2012). Despite the significant psychiatric limitations of living with SMI, the current study revealed

that 36 % of those who have experienced a ‘Criterion A’ event did not go on to develop PTSD. Future research may seek to explore risk and resilience factors for the development of PTSD in this highly traumatized and psychiatrically compromised population. Not surprisingly, psychological distress among participants was generally high and above clinical cut-offs for both study groups. These findings fall in line with previous literature which identifies SMI populations as having poorer outcomes on a range of psychiatric functioning and symptom severity inventories. Though both groups reported significant psychological distress, the SMI-PTSD group’s scores were significantly higher, indicating a more taxed psychiatric state. These findings are suggestive of the lasting effects of trauma and, more specifically, that the presence of PTSD may exacerbate distress above and beyond that seen among individuals with SMI alone.

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Table 5 Regression analysis summary for predicting psychological distress among trauma exposed participants (n = 75) Step and regression variables

B

SE B

b

t

p

Step 1: PTSD symptom severity on psychological distress

.05

.00

.80

11.18

\.00

Step 2: PTSD symptom severity on avoidance coping

.18

.03

.53

5.28

\.00

Step 3: PTSD symptom severity on psychological distress, controlling for avoidance coping

.04

.00

.26

8.40

\.00

R2 = .68 (n = 75, p \ .001)

The coping strategies used by this heavily burdened population were assessed as a whole and between study groups. Within the overall group, neither avoidance nor problem-focused coping emerged as a more often used strategy. However, differences revealed between the two study groups (SMI vs. SMI-PTSD) for avoidance coping indicated that those diagnosed with SMI-PTSD utilize avoidant coping strategies to a greater extent than individuals with SMI alone. This finding supports previous literature within the field of trauma recovery, suggesting that avoidance is a prevalent emotional and behavioral strategy used by individuals with PTSD (Fortier et al. 2009; Galor and Hentschel 2012; Schuettler and Boals 2011). The temporal relationship between the development of PTSD (in which avoidance is inherent) and utilization of avoidance coping strategies to address life stressors in general cannot be determined from this study. However, it may be concluded that for those individuals suffering from SMI, and undoubtedly also at higher risk for trauma exposure, reliance on avoidance coping strategies in dealing with life stressors may translate to the development of PTSD upon experiencing a traumatic event. The promotion of alternative coping strategies in this high risk population may decrease the likelihood of the development of PTSD. Problem-focused coping did not emerge as a strategy that was used more often by a particular group. The mean scores between the two groups are fairly equal, indicating that problem-focused coping may be utilized to a similar extent by the groups. When comparing the problem-focused scores from the current study versus those published in the previous literature, few differences emerge. That is, our sample produced fairly similar mean scores for problem-focused coping as it relates to coping with specific life stressors (Phillips et al. 2009; So and Wong 2008). Our sample used problem-focused coping to a similar extent as some other SMI samples, indicating that it is a used, but possibly not a favored, coping strategy for the population. Further study of what is associated with and predicts problem-focused coping is needed to more fully understand the occurrence and potential benefits of this coping style. Not surprisingly, PTSD symptom severity appears to significantly contribute to overall psychological distress experienced by trauma-exposed individuals suffering from

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SMI. Subsequent analyses demonstrated that the role of avoidance coping partially mediated this relationship. Taken together, for those who have been exposed to trauma the experience of psychological distress is at least partially accounted for by the ways they have been coping with difficult life experiences. The presence of the PTSD diagnosis alone, by definition, adds significant distress to an individual suffering from SMI’s already full plate. These results suggest that treating PTSD in a primary fashion should not only have the desired effect of reducing PTSD symptoms, but should also influence general distress as well. This possibility and these results should be taken into account when developing interventions for this comorbid population. These findings support recent discussion and efforts among community mental health researchers and clinicians to bring evidence-based trauma-focused services, including both assessment and interventions to CMHCs (Christensen et al. 2005; Frueh et al. 2009; Harris and Fallot 2001a, b; Substance Abuse and Mental Health Services Administration 2010). The recommendations offered by these clinicians and organizations acknowledge the challenges associated with disseminating evidence-based practices within CMHCs and highlight the importance of multi-level staff trainings that work toward the development of a trauma-informed system of care. Limitations and Future Directions These findings are not without their limitations. Though we can demonstrate group differences in psychological distress and coping, the data are limited in their ability to describe any temporality or developmental course. That is, our findings show that psychological distress is higher among the SMIPTSD group, but we cannot assert that the comorbid diagnosis of PTSD is the cause of, or even the most influential element leading to increased psychological distress. Similarly, results indicated that avoidance coping plays a meaningful role in the relationship between PTSD symptom severity and overall psychological distress, but it is likely not the only factor contributing to the translation of trauma sequelae to overall psychological distress. Additionally, as a cross-sectional, assessment-based investigation, we can

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draw few conclusions about the impact of coping strategy use on expression of psychopathology. Future research would benefit from exploration of other contributing variables to psychological distress, such as substance use, trauma type, and social supports. This could elucidate the complex nature of the psychological distress experienced by those with SMI and could identify treatment priorities in terms of mitigating such distress. Additionally, more thorough investigations of how avoidance coping is developed and its efficacy in the face of different types of life-stressors would further our understanding of the utility of this often-used coping strategy. While the current study has limited range to suggest treatment options, future investigation of coping among SMI populations may benefit from exploration of experientiallybased strategies in which mindfulness is used as a direct counter to avoidance-focused cognitions and behaviors. Lastly, increased samples sizes and longitudinal data would clarify questions regarding the impact of PTSD and how individuals with SMI cope with their varied psychosocial stressors.

Conclusion The current investigation contributes to a line of burgeoning evidence demonstrating that among those with SMI receiving services at CMHCs rates of lifetime trauma exposure are substantial. These findings support recent discussion and efforts among community mental health researchers and clinicians to bring evidence-based traumafocused services, including both assessment and treatment interventions to CMHCs (Christensen et al. 2005; Frueh et al. 2009; Harris and Fallot 2001a, b; Substance Abuse and Mental Health Services Administration 2010). Results from this study demonstrate that between two groups of SMI individuals, those with a comorbid diagnosis of PTSD report greater psychological distress and increased use of avoidance coping, suggesting that the additive effects of a PTSD diagnosis further tax those already living with an SMI. This study showed that the relationship between psychological distress and PTSD symptom severity is partially mediated by the way trauma-exposed SMI individuals cope with stressful events, namely through avoidance-based coping. Taken together, these findings add to the relatively scant literature on coping strategy use among SMI and SMIPTSD individuals and provide some guidance for increasing clinical focus on improving coping strategies as a means of reducing the effects of stress and traumatic stress on this high risk population. Acknowledgments The authors would like to acknowledge Jared Israel, M.A. and Micah Casey, B.A. for their role in the collection of

671 data used in the current investigation. We also thank Tony Hilkin and the Places for People Outreach Team for their selfless commitment to supporting those most in need.

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