MENTAL HEALTH NURSING

Effectiveness of psychoeducation intervention on post-traumatic stress

disorder and coping styles of earthquake survivors
Fahriye Oaz 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 2006
Accepted for publication: 12 March 2007
Correspondence:
Fahriye Oaz
Gu lhane Military Medical Academy
School of Nursing
Etlik 06018
Ankara
Turkey
Telephone:90 312 304 39 47
E-mail: foaz@gata.edu.tr/foaz@yahoo.com
OFLAZ F, HATI POG OFLAZ F, HATI POG

LU S & AYDI N H ( 2008) LU S & AYDI N H ( 2008) Journal of Clinical Nursing 17,
677687
Effectiveness of psychoeducation intervention on post-traumatic stress disorder and
coping styles of earthquake survivors
Aims and objectives. The aim of the study was to examine the effectiveness of a
psychoeducation intervention based on Peplaus approach, including problem-
solving compared with intervention with medication on post-traumatic stress
disorder (PTSD) symptoms and coping of earthquake survivors.
Background. Post-traumatic reactions and recovery are the result of complex
interactions among biological, personal, cultural and environmental factors. Both
psychosocial and psychopharmacological methods have been advised to treat PTSD.
The general goal of treatment is to decrease the anxiety and to support these patients
in regaining normal daily functions.
Design. The study used a pretest to posttest quasi-experimental design with three
comparison 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 as
psychoeducation 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 Coping
Strategies Scale were used for the measurements.
Results. There was a signicant difference between the PEM group and the
medication only group with the rst 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 signicant positive
correlations 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 combined
treatment model. Nurses can help the patients with PTSD by teaching them to cope
with the symptoms.
Relevance to clinical practice. The number and variety of catastrophic events in the
world are increasing. Psychiatric nurses should therefore take responsibility
regarding the effects of trauma and investigate the ways of working with people
who experienced trauma in more detail and develop interventions based on scientic
evidence.
Key words: coping, nurses, nursing, psychiatric nursing, traumatic stress.
Introduction
Disasters are large-scale events that affect signicant number of
people at the same time and are beyond individual control.
Among the natural disasters, earthquakes are very common
and one of the most devastating. Unlike other catastrophic
events, prediction of or preparation for earthquakes is not
possible 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 the
most devastating earthquakes, measuring 74 and 72 on the
Richter scale, occurredin1999. These earthquakes hit the most
densely populated district in Turkey within three months. In
addition to the people who were affected directly, thousands of
people either got involved in rescue efforts or witnessed painful
experiences during and after these earthquakes. Related to
these earthquakes, Bas og lu et al. (2002) reported that the
estimated rate of post-traumatic stress disorder (PTSD) among
the earthquake victims was 43%just after the event. In another
survey, Livanou et al. (2002a,b) found that the rate of PTSD
among the survivors was 63% 14 months after the event and
S alcog lfu et al. (2003) reported that the prevalence of PTSD
was 39% among victims that had not sought treatment
20 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 the
symptomatology and intervention approaches in the litera-
ture, there are very few studies about the psychological and
social consequences of disasters in Turkey. The lack of
knowledge and an intervention model to deal with persons
with PTSD are challenges in daily clinical practice, partic-
ularly in nursing. As there is an urgent need to be prepared
for large-scale disasters and deal with the extensive psycho-
pathology, an increased understanding of the responses of
survivors and cost-effective intervention models are still
needed.
Background
Various studies on disaster victims indicate that PTSD and
major 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 is
a chronic and disabling disorder associated with increased
substance abuse, suicidal ideations, comorbid psychiatric
disorders and physical health problems in the long term.
These adverse effects of the disorder create an increased
economic 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 treatment
models, there are still no studies convincingly dening long-
term effects of the treatment. To date, little is known about
the factors related to the treatment results and how to help
individuals with PTSD is a challenge for mental health
professionals.
Post-traumatic psychopathology and recovery are the
result 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 psychopharmacological
approaches have been used to help persons with PTSD and
these combined therapies are most frequently recommended.
In general, the goal of treatment is to decrease the anxiety and
to 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 Peplaus develop-
mental theory will be helpful to psychiatric nurses in
interviewing individuals and constructing interventions.
Peplau denes nursing as a therapeutic and interpersonal
process and the theory is suitable for short-term individual
therapy (Ryles 1998, Birol 2000).
According to Peplau, the patients health depends on the
reduction of anxiety. In other words, good health depends
F Oaz et al.
678 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd
primarily on diminishing anxiety and what diminishes
anxiety is communication. The patientnurse relationship
should be directed towards decreasing the severity of anxiety.
The core of Peplaus model is an interpersonal process and in
this relationship the nurse directs the purpose and the process
itself. In the process of patientnurse interaction, the nurse
plays a role as an advisor, source, instructor, technical expert,
leader and representative.
According to Peplau, tension appears when individuals
face stressful situations and this tension creates energy. This
energy is used either in a positive or negative way and health
is inter-related with the use of this energy caused by stress in
a positive way. The response to stress depends on the
intensity of the event and the capacity of the individual to
respond. The rst aim of nursing is to sustain the vitality of
the organism and then help the patient understand what the
health problem is. The nurses help the patient use the
stressful situation as a learning experience to gain new
behavioural patterns. Nurses help individuals understand
their own reactions and coping mechanisms and therefore
protect them from illness and future recurrences (Pearson
et al. 1996, Birol 2000). In this context, the concepts and
principles explained in Peplaus patientnurse relationship
overlaps PTSD treatment and psychosocial theories that
enable patients to overcome trauma. Peplaus interaction
process is materialized in four phases (Pearson et al. 1996,
Birol 2000).
Orientation phase
Both the patient and the nurse understand the complex nature
of the illness that the patient has gone through. At this stage,
the necessary information to dene the problem is collected.
The nurse has an advisory role. The nurse redenes the
problem and directs the patients energy away from anxiety,
aiming to handle the actual problem in a more constructive
way.
Identication phase
This phase begins after the patient accepts that a certain
relationship developed with the nurse and the nurse plans
appropriate action. This is the stage where patients express
their feelings and share the problem.
Exploitation phase
In this phase, the patient denes the service provided by
the nurse and experiences reactions directed towards this
service. Both the patient and the nurse work towards
mutually dened targets. According to the circumstances,
the nurse may play an advisory, source, technical expert or
other roles.
Resolution phase
After the resolution of the health problem, the patient does
not demand the assistance provided by the nurse. The patient
shows independent behaviours and is hopeful and open to
development. This phase is where the interaction between
individuals ends.
Peplau proposed the idea that during the orientation stage
it is more important to focus on the persons individual
development rather than the disease process and therefore
give the patient an opportunity to learn from this experience.
The nurse assists the patient throughout the interaction to
transform 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 be
related to the symptoms and the course of the disorder. When
a traumatic event happens, pre-event coping strategies of
individuals may no longer be adequate and new skills need to
be gained. That is why it is important to help individuals to
cope with the disorder and environmental adversity. In fact,
the factors affecting coping strategies also affect PTSD
symptomatology (Solomon et al. 1988, Spurrell & McFarlane
1993). The rst step is to help individuals with PTSD to
describe the symptoms and to reduce the adverse effects of
trauma while building trust by means of therapeutic
communication. Lazarus (1993) suggested that those who
use a problem-solving approach have a lower risk of
psychopathology, less depression, less anxiety and have an
internal locus of control. He also added that problem solving
can be counterproductive and cause chronic stress when it
fails. However, Spurrell and McFarlane (1993) indicated that
using coping strategies was associated with various kinds of
psychopathology but not PTSD; they found different coping
modalities were being used in acute and chronic PTSD. In
addition, Arata et al. (2000) found that PTSD was associated
with avoidance as a coping strategy. In conclusion, there is a
requirement for discovering and dening ways to overcome
trauma for individuals still facing this disorder. In this study,
we aimed to show the effectiveness of the nursing approach in
assisting patients.
Method
Aim
The primary purpose of this study was to compare the
effectiveness of different intervention models including psy-
choeducation with medication (PEM), psychoeducation only
(P) and medication only (M) in reducing symptom severity
and enhancing adaptive coping strategies for persons with
PTSD.
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 31
November, 2000 at the Psychiatric Outpatient Clinic of the
Gu lhane Military Medical Academy in Ankara. Patients were
recruited for the study ve months after the earthquake.
Patients came to this clinic on a daily basis as walk-ins, with
scheduled appointments, or on ofcial sick calls.
All participants of this study were patients who voluntarily
presented at the psychiatric outpatient service either because
of PTSD symptoms or other mental health concerns. They
were the persons who had experienced the earthquake.
Within the study process, those patients who had experienced
the earthquake were assessed for PTSD by a psychiatrist and
those who met PTSD criteria were referred to the researcher.
Primary physician determined the diagnosis of PTSD and
whether they needed medication or not. The researcher
informed all of the patients diagnosed with PTSD, about the
study and assessed each patients eligibility for enrolment. All
patients, whether prescribed medication or not, were asked if
they were willing to participate in the psychoeducation
sessions 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 patients
who were not prescribed medication but willing to partici-
pate to psychoeducation. Following the eligibility assessment
and obtaining informed consent, patients were asked to
complete pretest questionnaires and were given a follow-up
appointment. The posttest questionnaires were given one
week after the last psychoeducation session. The average time
for completing the questionnaires was 45 minutes.
Participants who were in the medication only group were
also asked to complete the pretest and posttest question-
naires. The pretest questionnaires were administered during
the initial visit to the psychiatric outpatient department while
the posttest questionnaires were given seven weeks later.
Participants were interviewed in a private room in the
outpatient department throughout the study.
Participants
It was aimed to reach all the patients diagnosed with PTSD
within the rst year following the earthquake. Therefore,
during the study, 169patients were diagnosedwithPTSDat the
psychiatric outpatient clinic at Gulhane Military Medical
Academy and 68 of these tted the study sample criteria for
inclusion: (1) diagnosed as earthquake-related PTSD; (ii) older
than 18 years of age; (iii) literate in Turkish; (iv) willing to
participate in the study; (v) no other diagnosed psychotic
disorder; (vi) no recent psychological treatment (including
medication andpsychotherapy); (vii) no braininjury. Excluded
patients were: those who had experienced other traumatic
events such as combat, sudden loss of a loved one, or trafc
accidents; those with co-morbid psychiatric disorders (except
depression); and those who did not t the inclusion criteria. Of
the eligible 68 patients, 17 (25%) patients were not willing to
receive any treatment or psychoeducation.
Signed informed consent was obtained from each partici-
pant. Patients who participated in the study were military
personnel and their family members who were diagnosed as
having earthquake-related PTSD, with 784% (n 40) of
the participants living in the epicentre of the earthquake area
(
_
Izmit, Go lcu k, Yalova, Bolu) when the earthquake
occurred. After the rst introduction interview, 21 patients
(412%) were assigned to the psychoeducation and medica-
tion group, 16 (313%) patients were assigned to the
medication-only group and 14 (275%) patients to the
psychoeducation group.
Structure of psychoeducation intervention
Six sessions were conducted, each approximately one week
apart. The content of the psychoeducation was based on
problem-solving stages and the progress was achieved by
interviews based on Peplaus interpersonal relationship model
(Molloy 1999). The sessions were usually 6090 minutes in
length. Posttests were administered one week after the sixth
session.
PTSD diagnosis and
medication determination
Administration of
questionnaires and
assignment into groups
Psychoeducation + medication
Medication alone
Psychoeducation alone
Psychiatrist
Assessment by
and consent
Eligibility assessment
Figure 1 Protocol for assignment to the
intervention groups.
F Oaz et al.
680 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd
The interviews were planned and executed in the following
way:
First interview
Patients were interviewed on their opinions, feelings and
beliefs on the traumatic experience and what it signies to
him/her. The interviews were documented by the investi-
gator as short notes. During the interviews, questions about
the subject matter were directed to patients and the accu-
mulated information was evaluated by the investigator and
categorized under the headings of data collection forms.
Second interview
Information was provided to the patients on the reason,
nature, symptoms and treatment methods of PTSD and
their questions were answered. The rst step in helping
these patients is to dene key symptoms. The changes in
the lifestyle of patients, feelings, opinion and behavioural
reactions caused by the illness were discussed in this
session.
Third interview
Information about stress and coping with stress were pro-
vided by summarizing the previous interview. The coping
methods used by the patients before the trauma, the cur-
rent coping methods and how they perceived them were
discussed.
Fourth interview
The previous interview was summarized with the patient and
information about problem-solving concept and stages pro-
vided. The opinion and beliefs of the patient about the subject
matter were asked for afterwards. By asking the patient to
rank the currently perceived problematic situations (due to
disorder or other), the problems were redened as resolvable
or concrete problems. Information about target determin-
ation and choosing attainable and realistic targets and alter-
natives was then given.
Fifth interview
The goals and alternatives chosen with the patient were
studied. What to pay attention to when determining targets
and alternatives was emphasized. The time to reach the target
was stressed and the patient asked to work on putting these
into practice.
Sixth interview
Information about evaluating results was provided and the
problems faced during the application and their reasons and
the developments were discussed. The process during the
programme in general was reviewed and the opinion of the
patient was taken. At the end of the interview, the tests were
applied again. The scales were reapplied to the individuals
present in the comparison group and not receiving any
treatment 68 weeks after the rst test was applied.
The framework of the interviews was developed and
dened according to Peplaus developmental nursing model.
The tests applied are equivalent to orientation for the rst
meeting, denition for the second and third interviews,
beneting for the fourth and fth interviews and resolution
for the sixth interview. The interviews were documented
according to the recommended SOAP format. In this format
(S) stands for the subjective life explained by patient, (O)
stands for the objective observation of the nurse, (A) stands
for assessment or in other words data accumulation and
analysis and (P) stands for the action plan decided upon
(Pearson et al. 1996, Ryles 1998, Birol 2000). The content of
the sessions is summarised in Fig. 2.
Measures
Post-traumatic stress disorder symptom severity, depression
level and coping strategies were the outcome measures of
this study. To measure these outcomes, the Clinician
Administered PTSD Scale (CAPS), Hamilton Depression
Scale (HDS) and Coping Strategies Scale (CSS) were used.
As depression is the most common co-morbid disorder with
PTSD, it was measured to control for the confounding
effect.
The patients were rst assessed through the CAPS to obtain
a symptom severity score. The CAPS contains 17 items for
PTSD symptoms and the total score is obtained by adding
frequency scores to severity scores (Blake et al. 1995, Aker
et al. 1999). The HDS was then administered to identify the
co-morbidity of depression. The HDS is a 17-item scale and
measures severity and rates of depressive symptoms (Williams
1978, Akdemir et al. 1996). The CSS was next administered
to evaluate the coping strategies of the participants. The CSS
is a 33-item Likert scale consisting of three subscales: social
support seeking, avoidance and problem solving. The reliab-
ility and validity studies of all scales have been conducted and
published by Turkish researchers (Amirkhan 1994, Aysan
1994).
The data regarding factors that were addressed as contri-
buting to PTSD symptom severity such as demographics (age,
gender, marital status, economic status, psychiatric morbidity
history), characteristics of traumatic experience (loss, having
been trapped, physical injury) and life changes after the
earthquake (relocation, resources of social support) were
obtained by using a questionnaire.
Mental health nursing Post-traumatic stress disorder and coping
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd 681
Data analysis
The sample size for the analysis was 51 and this number was
used for all analyses presented. The frequencies of demo-
graphics were rst obtained and compared by intervention
groups using the chi-squared test to evaluate the homogen-
eity of the groups; correlation analysis was then performed
to evaluate the relationships between the PTSD symptoms
and coping strategies; paired samples t-test was used
following the intervention to evaluate the difference between
pretests and post-tests in each intervention group; the
effectiveness of the intervention approaches was evaluated
with the univariate analysis of covariance (ANCOVA ANCOVA) by
controlling pretests and multiple linear regression analysis
was used to explain the effect of coping strategies on PTSD
and depression scores.
Results
Characteristics of the patients and the traumatic
experience
The mean age of the participants was 327 (SD 127); none
of participants was using any treatment when they partici-
pated in the study. The demographic characteristics of the
participants are presented in Table 1.
The factors related to trauma severity and contributing to
the symptomatology following the earthquake were as
follows: 294% (n 15) of the participants had been trapped
under rubble, 314% (n 16) had a physical injury, 706%
(n 36) had experienced loss of at least one acquaintance
because of the earthquake and 451% (n 23) reported
ongoing nancial difculties after the earthquake. Thirty-
eight of the participants (745%) reported that they had
received insufcient social support after the earthquake.
These answers were based on the participants view.
There was no statistically signicant difference among the
three intervention groups when compared for participant
characteristics except for education levels, having experi-
enced loss and perceived economic distress. In addition, there
was no difference among the groups regarding coping
strategies. However, there was signicant difference between
the medication only (M) group and psychoeducation only
1. Orientation phase:
Talked about patients
perceptions (their
feelings, beliefs and the
meaning of event)
2. Identification phase:
Provided information
about PTSD (nature of the
disease, symptoms and
treatment methods) and
talked about patients
problems
3. Identification phase:
Provided a description of
related stress and coping
and talked about patients
coping strategies
4. Exploitation Phase:
Provided information about
problem-solving and talked
about how patient solves
problems
5. Exploitation Phase:
Problems, objectives and
alternative solutions, as
determined by each patient
were individually discussed.
6. Resolution Phase:
The patient was
encouraged to talk
about the whole process
Figure 2 The content of psychoeducation
sessions.
Table 1 Characteristics of participants
n %
Gender
Male 19 373
Female 32 627
Education
<8 years 11 216
811 years 25 490
>11 years 15 294
Marital status
Married 23 431
Single 20 392
Other 8 157
Location
Epicentre 40 784
Out of the epicentre 11 216
Psychiatric disorder history
Yes 19 373
No 32 627
F Oaz et al.
682 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd
(PE) group when the post-traumatic stress scores (Bonferroni
test F 1349, d.f. 2, p 0045) were compared and
between the PE and PEM groups for depression scores
(F 766, d.f. 2, p 0018). The participants in the PE
group had lower mean scores. Hence, ANCOVA ANCOVA test was used
to control that difference among the groups for the analysis
of measurements in post-tests.
Pretest to post-test comparison of intervention groups
Table 2 displays the means and SD of the scores on the
symptom and coping strategies scales. The paired samples
t-test was used to compare the pretests and posttests
despite the small sample size as the variances were
homogeneous within the groups. Posttest scores of post-
traumatic stress and depression were signicantly lower
compared with the pretests in all intervention groups, while
problem-solving scores were higher in those participating in
the PEM intervention. Social support-seeking scores in-
creased in the M group and avoidance decreased in the
PEM and M groups. There was no difference between
pretests and posttests for coping strategies in the PE group
(Table 2).
The univariate ANCOVA ANCOVA test was used for all posttest
outcomes to evaluate the effectiveness of intervention. Table 3
shows the adjusted means of post-test scores by controlling
for pretest scores. There were signicant differences among
the intervention groups in post-traumatic stress, depression
and problem-solving approach scores.
There were signicant differences between the PEM and M
intervention groups in post-tests for PTSD, depression and
problem-solving scores. The post-traumatic stress scores of
the M group were signicantly higher than the other two
groups after the intervention and the PEM group differed
signicantly from the M group for depression and problem-
solving scores. The depression scores were decreased and
problem-solving scores were increased signicantly in the
PEM group. In general, there was no difference in outcome
scores of the PE group compared with the other two
intervention groups.
Correlation between the symptoms and coping strategies
In evaluating of pretests and post-tests, there was a statisti-
cally signicant positive correlation between PTSD scores
and depression scores (pretest, r 0618, p < 0001; post-
test, r 0676, p < 0001). Those who had lower avoidance
tended to have higher social support-seeking scores
(r 0391, p 0005), lower depression (r 0359,
p 0010) and lower PTSD scores (r 0504, p < 0001)
on posttests. In addition, social support-seeking was also
negatively correlated with PTSD scores (r 0363,
p 0009), while those who had lower PTSD scores tended
to have higher social support-seeking scores.
Table 2 Pretest and post-test results
Pretest Post-test
t* d.f. p Mean SD Mean SD
Post-traumatic stress
Psychoeducation medication 6161 1277 4052 1337 929 20 <0001
Medication only 6306 1503 5293 1624 558 15 <0001
Psychoeducation only 4957 1667 3114 1633 445 13 0001
Depression
Psychoeducation medication 2109 950 1019 317 751 20 <001
Medication only 1756 708 1293 507 458 15 <0001
Psychoeducation only 1342 719 892 446 342 13 0004
Problem solving approach
Psychoeducation medication 2447 693 2680 361 210 20 0048
Medication only 2431 440 2437 350 0083 15 0935
Psychoeducation only 2557 444 2678 450 166 13 0119
Social support seeking
Psychoeducation medication 2404 497 2514 440 179 20 0087
Medication only 2306 475 2518 475 457 15 <0001
Psychoeducation only 2535 506 2635 416 147 13 0165
Avoidance
Psychoeducation medication 2233 363 2133 407 235 20 0029
Medication only 2481 360 2337 265 243 15 0028
Psychoeducation only 2178 420 2135 387 0777 13 0451
*Paired samples t-test.
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2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd 683
Multiple linear regression analysis was applied to analyse
the effect of coping strategies on PTSD and depression scores.
Problem-solving, social support-seeking and avoidance to-
gether showed signicant correlation with PTSD (R 0570,
R
2
0324, p < 005) and depression scores (R 0396,
R
2
0157, p < 005). Overall, coping strategies explained
32% of the total variance in the PTSD scores and 15% of the
total variance in the depression scores. Avoidance scores
shows positive and moderate correlation with the PTSD and
depression scores (Table 4). Avoidance had a particularly
important effect on PTSD symptom severity and depression
scores (p < 005).
Discussion
Life-threatening and overwhelming situations can destroy the
pre-existing coping skills of individuals and new coping
strategies are needed to provide dramatic changes. Anxiety
and hyperarousal lead to dependent behaviour and decreased
autonomy and Bas og lu et al. (2003) and Livanou et al.
(2002a,b) have recommended focusing on the individuals
sense of control for treatment approaches for patients with
PTSD. As Peplau indicated, the nurses role is to facilitate the
transfer of energy made available by anxiety to adaptive help-
seeking behaviours and coping strategies and an intervention
model based on this nursing model and problem solving can
be supportive for these patients (Molloy 1999). However, it is
important to remember that this may not be sufcient if the
symptoms are persistent and repetitive. As the nature of
PTSD is persistent and long term, medical treatment com-
bined with a psychosocial approach is considered more useful
for these patients.
The present study showed that PTSD and depression scores
decreased signicantly in each intervention group following
the interventions. The patients in the PEM group had the
greatest decrease in symptom level and took advantage of
psychoeducation; both measures of PTSD and depression
were signicantly decreased and avoidance scores decreased
as problem-solving scores increased in this group. In the M
group, social support-seeking scores increased in contrast to
the other two groups, but no signicant improvements were
evident in the PE group, compared with the coping strategies
Table 3 Comparisons of adjusted means of post-tests by intervention groups
PEM (n 21) PE (n 14) M (n 16)
*F d.f. p Mean SE Mean SE Mean SE
Post-traumatic stress 3841 235 3795 301 4975 271 612 2 0004

Depression 891 0656 1069 0811 1306 0725 898 2 0001

Problem-solving approach 2693 0596 2637 0733 2457 0684 351 2 0038

Social support seeking 2518 0490 2537 0605 2599 0565 0619 2 0543
Avoidance 2183 0440 2230 0543 2188 0520 0244 2 0785
*ANCOVA ANCOVA test; Bonferroni test:

medication group is different from the other groups;

psychoeducation medication group is different from the
medication group.
PEM psychoeducation medication; PE psychoeducation only; M medication only.
Table 4 Regression analysis of coping
strategies
B SE b T p
Correlations
Zero order Partial
Post-traumatic stress*
Constant 4192 2649 158 0120
Problem-solving approach 0857 0525 0197 163 0109 0260 0232
Social support seeking 0745 0507 0192 147 0148 0363 0210
Avoidance 187 0608 0404 308 0003 0504 0411
Depression

Constant 8008 764 104 0300

Problem-solving approach 0184 0152 0164 121 0232 0206 0174
Social support seeking 0408 0146 0041 0279 0781 0178 0041
Avoidance 0388 0175 0323 221 0032 0359 0307
*R 0570, R
2
0324, F 752, p 0000.

R 0396, R
2
0157, F 0292, p 0044.
F Oaz et al.
684 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd
in this study. As stated in several studies, persons with PTSD
are most likely to benet from combined therapies, as
psychopharmacological treatment decreases anxiety levels
quickly (Davidson & Connor 1999, Foa et al. 1999, Aker
2000). Despite the decrease in symptom levels, PE interven-
tion by itself did not change the coping strategies of the
patients in this group. Overall, there was no difference in the
PE group compared with the M and PEM groups in the post-
test scores.
It may be postulated that, when anxiety in patients handled
with a combined approach is treated with medication, the
patient will benet from the counselling to the extent desired
and the changes in this groups scores support this notion.
The result obtained is consistent with other articles stating
that Peplaus theory is appropriate for short-term individual
treatment of individuals with anxiety and depression (Ryles
1998).
The needs of individuals who experienced trauma vary. It
is important to nd methods for patients to control their own
life (Clark 1997). Medication treatment together with coun-
selling focusing on the individuals needs will enable achiev-
ing positive results in these patients. Although medicines may
be helpful, they constitute only one part of the treatment and
listening to patients and explaining their situation, as can be
provided by the nurse, are very important in PTSD (Petit
1991).
Even if these patients consciously leave behind the trauma,
the anxiety and intense stimulation will remain. Persons
regress to earlier periods in coping with post-traumatic stress.
This situation shows itself in adults with dependency and the
inability to take autonomous decisions (Van der Kolk, Van
der Hart & Burbridge 1995,Yehuda 1999). Problem-solving
is a behaviour that can be learned and even if the medication
treats symptoms it may not be sufcient to provide problem-
solving skills which will enable the individual to have long-
term good health. In this study, medication together with this
short-term counselling has enabled the reduction of symp-
toms and provided an increase in the patients problem-
solving skills.
In terms of coping strategies, PTSD severity seems to be
related to avoidance scores. Maladaptive coping strategies
may be related to psychopathology as indicated by Holahan
and Moos (1987). Social support has always been an
important factor when coping with difculties. As patients
with PTSD suffer from avoidance, this symptom can appear
as a coping but prevent seeking social support and help.
A nding supporting this notion from our study was the
increasing social support-seeking scores while avoidance was
decreasing and increased social support-seeking correlated
with lower PTSD scores. As avoidance decreased, PTSD
severity was also decreasing indicating that PTSD severity can
be reduced and chronicity may be prevented if avoidance can
somehow be managed. On the other hand, Rabin and Nardi
(1991) indicate that higher PTSD severity causes higher
avoidance. Teaching adaptive coping strategies can therefore
be an effective approach for individuals with PTSD who live
in societies that use avoidance as a common coping strategy,
as in Turkey. Persons should be taught that avoidance is not
an effective coping strategy and contributes to symptom
severity.
Conclusions
Participants who had psychoeducation and medication
together beneted more than those on medication or
psychoeducation only in this study. Psychoeducation had
some positive effects on participants, but anxiety and
hyperarousal are expected to create obstacles to learning
and using adaptive coping strategies. An additional support-
ive and educational approach can therefore be more useful
for these patients to get the added benet of a rapid decrease
of anxiety with medication. Despite the decrease in symptoms
with medication, individuals still need to learn how to deal
with new life situations and PTSD symptoms after a
traumatic experience. Avoidance as a coping strategy inu-
ences the results of the interventions and nursing staff should
be aware of how the patients deal with their difculties and
symptoms. The long-term effectiveness of the treatment
approaches should to be investigated by follow-up studies.
All rates of PTSD symptoms and traumatic experience were
based on self-report and the study used a small sample size that
may have caused results to be underestimated. However,
sample sizes of the groups were small but there were no
difference among the groups regard to sociodemographic
characteristics and this homogeneity among the groups
provides the reliability of the statistics. On the other hand, as
randomization is usually a challenge inthese studies, the results
should be supported by future studies. Finally, this study may
be considered as an important contribution to the development
of a nursing care model to help persons with PTSD.
Contributions
Study design: FO, HA, SH; data collection and analysis: FO,
HA; and manuscript preparation: FO, SH.
Acknowledgements
This study is based on the authors doctoral dissertation. The
research was supported by the Gulhane Military Medical
Mental health nursing Post-traumatic stress disorder and coping
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd 685
Academy, Department of Psychiatric and Mental Health. The
authors thank Linda Rose, PhD, APRN, Associate Prof. and
Ada R. Davis, PhD, APRN-BC, ELS, Prof. for their
invaluable advice and encouragement while preparing the
manuscript for publication.
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