Narrative Exposure Therapy Study for PTSD Among the Homeless Population

Study Overview
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Brief Summary
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The purpose of this study is to assess the acceptability and feasibility of delivering Narrative Exposure Therapy to homeless individuals with Post-Traumatic Stress Disorder. In Ottawa, in 2015, there were 6,825 people using 500,191 bed nights in the city emergency shelters (Alliance to End Homelessness in Ottawa 2015 Annual Report) with approximately another 500 sleeping on the streets (The Homelessness Community Capacity Building Steering Committee 2008 Ottawa, ON). Mental health disorders, including substance abuse, are common in this population, are often under treated and can be a source of considerable distress and disability. In addition to the high rates of mental disorder, there are three other significant factors which impact morbidity. First, a history of significant childhood trauma is common which impacts relationships and ability to cope with difficulties. It is increasingly recognized that a trauma informed approach to providing services to the homeless population is needed. There have been no randomized controlled trials of treatment of post-traumatic stress disorder in the homeless population. Second, brain dysfunction from head injuries and attention deficit disorder appear to be common. Problems with brain dysfunction can cause difficulties especially with attention, impulsivity and managing relationships. Finally, life for the marginally housed can be chaotic with day-to-day uncertainty over accommodation, income and security. This means that providing health services to this population requires a degree of flexibility in terms of who provides services, where and when. These issues result in a population with complex needs that traditional mental health care is poorly equipped to serve. At present there is a clear gap in the provision of services that address the experience of trauma in homeless individuals. There are no services for trauma in publicly funded hospitals, which leaves private providers as the sole source of treatment. Other potential barriers include accounting for the effects of substance abuse, brain injury and chaos in this population. What the investigators are proposing is a pilot study to assess the feasibility and acceptability of providing a time-limited assessment and therapy (six sessions) within the shelter system to homeless individuals diagnosed with post-traumatic stress disorder.

Detailed Description
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The purpose of this study is to assess the acceptability and feasibility of delivering Narrative Exposure Therapy to homeless individuals with Post-Traumatic Stress Disorder. This includes assessing the feasibility of recruiting sufficient numbers of participants, conducting a randomized trial in the shelter system and achieving adequate participant follow-up rates. Study procedures will take place at shelters served by the Royal Ottawa Mental Health Centre's Psychiatric Outreach Team and Inner City Health, which are: The Shepherds of Good Hope, The Salvation Army, The Mission, Cornerstone Housing for Women, and other locations served by The Royal Ottawa's Psychiatric Outreach Team and Inner City Health. Homeless individuals who meet criteria for PTSD will be offered, in addition to usual care, six sessions of Narrative Exposure Therapy either with or without the option of receiving services from a genealogist to supplement the process of exploring their life narrative. A total of 24 participants will be recruited into this study and will be randomized in a 1:1 allocation. At the start of their involvement in the study, participants randomized to receive genealogical services will be provided with the option to access services from a professional genealogist, to trace their family history. Participants will be made aware of the fact that new family information will be revealed through this process, and also be informed of the standard methods that will be used to extract this information which could involve research through publicly available historical records or voluntary DNA testing. The primary outcomes for this study are acceptability - the investigators would deem the interventions acceptable if 50% of people approached consented to be randomized; and feasibility - the investigators would deem the study feasible if the planned sample size was recruited over a period of six months. Secondary outcomes include changes from baseline on relevant rating scales of symptoms, housing status, quality of life; and follow-up of participants three months from enrollment. This study will inform mental health treatment of this chronically underserved population.

Official Title
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Protocol for a Feasibility Study of Narrative Exposure Therapy in Homeless Individuals With Post-Traumatic Stress Disorder

Conditions
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PTSD

Intervention / Treatment
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* Other: Narrative Exposure Therapy
* Other: Genealogical Services


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients must: Be 18 years of age or older; Be referred to the study by the Psychiatric Outreach program at the Royal Ottawa Health Care Group or by Inner City Health; Meet DSM-5 criteria for post-traumatic stress disorder, as measured by the Mini International Neuropsychiatric Interview (MINI); and, Be homeless or vulnerably housed at the time of their screening visit, as measured by the Housing Status Questionnaire. Exclusion Criteria: Patients must not: Be unable to speak and understand English; Be unwilling to attend Narrative Therapy session for a period of six weeks; Be unwilling to return to a designated therapy location to complete study follow-up appointments; Be unwilling or unable to provide informed consent; Present to their study screening visit acutely intoxicated; Be, in the opinion of the Investigator, unlikely to commit to a 12-week study; or Pose a risk of harm to study staff or other clients.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Other
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Intervention: NET+G<br>In addition to usual care, participants will receive six sessions of Narrative Exposure Therapy over six weeks plus the option to receive genealogical services. | Other: Narrative Exposure Therapy<br>* Narrative Exposure Therapy attempts to place the trauma within a narrative of the person's life. Anecdotal evidence of using this approach in the homeless population is that constructing an autobiography helps to give meaning to their problems and provide the initial steps in constructing a core sense of belonging and identity. Six sessions of individual therapy allows for participants to work with a therapist one-on-one to position their experiences of trauma within their life story.<br>Other: Genealogical Services<br>* At the start of their involvement in the, study participants randomized to this group will be provided with the option to access services from a professional genealogist, to trace their family history. Participants will be made aware of the fact that new family information will be revealed through this process, and also be informed of the standard methods that will be used to extract this information which could involve research through publicly available historical records or voluntary DNA testing.<br>|
| Active Comparator: Intervention: NET<br>In addition to usual care, participants will receive six sessions of Narrative Exposure Therapy over six weeks. | Other: Narrative Exposure Therapy<br>* Narrative Exposure Therapy attempts to place the trauma within a narrative of the person's life. Anecdotal evidence of using this approach in the homeless population is that constructing an autobiography helps to give meaning to their problems and provide the initial steps in constructing a core sense of belonging and identity. Six sessions of individual therapy allows for participants to work with a therapist one-on-one to position their experiences of trauma within their life story.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Acceptability measured by Recruitment Rates | The investigators would deem the interventions acceptable if 50% of people approached consented to participate in the study. | 6 months | 
| Feasibility measured by Sample Size | The investigators would deem a larger study to be feasible if the investigators could identify the planned sample size (n=24) over a six month period. | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Acceptability & Feasibility of Collecting Outcome Data measured by Retention Rates | Collecting outcome data within this population will be determined acceptable/feasible if dropout and incomplete outcome assessment is limited to 25% of participants three months after the intervention. | 6 months | 
| Change in Post-Traumatic Stress Disorder (PTSD) symptoms as measured by the PTSD Checklist for DSM-5 (PCL-5) | The PTSD Checklist for DSM-5 is a 20-item self-report measure that assesses the presence and severity of PTSD symptoms. Items on the PCL-5 correspond with DSM-5 criteria for PTSD. The PCL-5 will be collected as part of the Narrative Exposure Therapy Session to quantify PTSD symptoms and traumatic experiences. Blevins et al. (2015) demonstrated that PCL-5 scores exhibited strong internal consistency (α = .94), test-retest reliability (r = .82), and convergent (rs = .74 to .85) and discriminant (rs = .31 to .60) validity. | Baseline, Week 8, Week 12 | 
| Change in Housing Status as measured by Self-Report from Participants | Any changes in housing status during the study period (including follow-up period) will be noted. This will be assessed by asking the participants directly about their current housing status throughout the study period. | Baseline, Week 4, Week 8, Week 12 | 
| Change in scores on Health-Related Quality of Life and Functioning as measured by the 20-item Medical Outcomes Survey Short Form Health Survey (SF-20) | This is a 20-item questionnaire that assesses various health outcomes, and the extent to which health related problems interfere with daily life. The SF-20 [27] uses questions related to 8 domains: physical functioning, role functioning (physical), bodily pain, general health, vitality, social functioning, role functioning (emotional) and mental health. Each item is scored on a scale of 0 to 100 and then averaged to obtain a sub-scale score. Sub-scale scores on the SF-20 are rated on a scale from 0 to 100, with high scores indicating a higher degree of functionality. | Baseline, Week 4, Week 8, Week 12 | 
| Change in Scores for Substance Use/Misuse as measured by the Addiction Severity Index (ASI) | A semi-structured interview used to assess severity of substance abuse problems. Questions are related to the following seven potential areas that could be impacted by substance use: Medical, Employment/Support Status, Legal, Family/Social and Psychiatric, as well as Alcohol specific and Drug specific questions. This interview gathers information on current (past 30 days) and lifetime substance abuse. Severity ratings are based on the following 10 point scale (0-9): 0-1 No real problem, treatment not indicated; 2-3 Slight problem, treatment probably not necessary; 4-5 Moderate problem, some treatment indicated; 6-7 Considerable problem, treatment necessary; 8-9 Extreme problem, treatment absolutely necessary. | Baseline, Week 4, Week 8, Week 12 | 
| Change in Scores for Alcohol Use/Misuse as measured by the Alcohol Use Disorder Identification Test (AUDIT) | The AUDIT questionnaire is designed to assess the following four dimensions of alcohol misuse: Alcohol consumption (3 items); Drinking behaviour (3 items); Adverse reactions (2 items); Alcohol-related problems (2 items). The first three items of the AUDIT (AUDIT-C) will be used as a screening questionnaire. Participants who score above 4 on the first three items of the AUDIT-C will be asked to complete the Full AUDIT. In men, a score of 4 or more is considered positive; in women, a score of 3 or more is considered positive. Generally, the higher the AUDIT-C score, the more likely it is that the patient's drinking is affecting his/her health and safety. For the Full AUDIT, a score of (0-7) indicates low-risk. (8-15) indicates risky or a hazardous level of drinking behaviours. (16-19) indicates high-risk or a harmful level of drinking behaviours. A score of (20 or more) indicates high risk alcohol related behaviours and an almost certainty of dependence. | Baseline, Week 4, Week 8, Week 12 | 
| Change in Health Care Costs as measured by Self-Report Questionnaire | A questionnaire has been created by the research team to capture data related to health care costs. The Health Care Costs questionnaire is an 11-item questionnaire that evaluates the effect of mental health on an individual's ability to work and perform regular activities. Specifically, elements from the Client Service Receipt Inventory (CSRI) and the Work Productivity and Activity Impairment Questionnaire: Specific Health Problem (WPAI: SHP) as well as other health cost indicators used in previous studies conducted by the Principal Investigator. | Baseline, Week 4, Week 8, Week 12 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Homeless Populations, PTSD, Narrative Exposure Therapy, Individual Therapy, Genealogy