Veterans may experience compounding traumas from the military context of their experience - PowerPoint Presentation

Slide1

Veterans may experience compounding traumas from the military context of their experience and exacerbation of stress symptoms from military culture that encourages stoicism and symptom suppression. Dialectical behavior therapy (DBT) focuses on regulating emotions and tolerating distress. This workshop will illustrate the usefulness and difficulties of utilizing DBT with veterans.

Healing the Warrior Within: Utilizing Dialectical Behavior Therapy to Restore the Mind, Body, and Spirits of Our Veterans

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Introduction: Learning Objectives

OIF/OEF/OND Treatment utilizationRisk of PTSD in the OIF/OEF/OND PopulationCompounding factors of the military cultureEmpirical evidence for DBT Why DBT?

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OIF/OEF/OND Veterans and Treatment UtilizationAs of September 30, 2011 there are 2.6 million Operation Iraq Freedom (OIF), Operation Enduring Freedom (OEF) and Operation New Dawn (OND) Veterans

*12% of the Veteran population

38% access Mental Health Services at a VAMC-*More than any other

eraSlide4

OIF/OEF/OND Veterans and Treatment UtilizationRecent conflict Veterans use of Mental Health Services has more than doubled since 2006

4% to 12%Of those that access Mental Health Services over half access some type of PTSD-related service

Very unlikely to complete full treatment protocol9.5% complete recommended number of sessionsSlide5

Why does this matter?Higher risk for suicide

Alcohol and drug useMental health problems continue to increaseRelationship issuesFamily consequencesIsolation from communityVocational consequencesSlide6

PTSD Prevalence in OIF/OEF/OND Population18.5

%-50.2% have a PTSD diagnosis14-16% have experienced PTSD symptomsMost common diagnostic category: Adjustment reaction

88% PTSD

Twice as likely to have an adjustment disorder reaction

How can we predict

who develops

PTSD

?Slide7

PTSD: DefinedPost Traumatic Stress Disorder (PTSD) is a maladaptive pattern in the stress response system.

Preceded by an individual experiencing a traumatic event in which the person experiences, witnesses or is confronted by an event that involves actual or perceived threat of death, serious injury or a threat to physical integrity of self or others. The

traumatic event must meet specific standards and the individual must experience a number of symptoms from the following areas: intrusion, avoidance, negative alterations in cognitions and mood and alteration in arousal and reactivity Symptoms must last a specified length of time, impair functioning and not be in response to a medical condition or substance abuse issue. A diagnosis of PTSD is indicated if an appropriate number of symptoms are present in each category (A= 1 required B=1 required; C=1 required; D=2 required, E=2 required),

symptoms last longer than one month, the disturbances creates

significant

distress or impairment in social, occupational, or other important areas of functioning and they cannot be attributed to a medical condition or substance use issue (APA, 2013). Slide8

PTSD: Associated Factors

Pre-Trauma Factors

Trauma CharacteristicsPost-Trauma Factors

Strong AssociationsNone

Trauma/combat exposure severity

Perceived

life threat

Combat-related injury

Peritraumatic

distress or disassociation

Lack of social

support, negative homecoming experience, exposure to additional life stressors

Intermediate Associations

Lower education, lower intelligence, lower military rank, lower socioeconomic status, prior trauma, prior psychiatric history/symptoms,

family psychiatric symptoms, family psychiatric history, behavioral problems in childhood, childhood abuse or adversity

Exposure to death, Killing or abusive violenceSlide9

PTSD Treatments for Veterans: VAMCEvidenced Based Treatment

Prolonged ExposureCognitive Processing TherapyCognitive Behavioral Therapy

MedicationsSlide10

Influencing Factors for Treatment Utilization

Factors

Study

Concerns

that treatment will not be kept confidential

Treatment will constrain future job assignments and military-career advancement

Unpleasant side effects of treatment

Mental health care is not effective OIF/OEF/OND feeling out of place at a VA facility

Delay or difficulty in scheduling appointments

Tanielian

&

Jaycox

, 2008

Stigma and beliefs about mental health care

United States Government Accountability Office, 2011

Lack of understanding or awareness of mental health care

United States Government Accountability Office, 2011

Logistical challenges to accessing mental health care

United States Government Accountability Office, 2011

Concerns about VA’s health care

United States Government Accountability Office, 2011

Clinic of first mental health diagnosis and distance from VA facility

Seal et al., 2010

Type and complexity of mental health diagnosis

Seal et al., 2010

Unstable housing, financial distress, unemployment or underemployment, divorce or separation

Jakupcak

&

Varra

, 2011Slide11

Influencing Factors: Military CultureMilitary Culture

Loyalty, Patriotism, ObedienceCompromised adaptation, flexibility & adjustment skillsStrict roles

Exhibit painful emotions and vulnerabilityDeploymentsConstant separation and reunionLack of community integration

Concealment of combat related fearsPostwar

Reintegrating into the family system and community

Vicarious trauma

Internal dissonance

Biological memorySlide12

DBT: OriginsDialectical Behavior Therapy (DBT), developed by Marsha

Linehan, Ph.D., ABPP, at the University of WashingtonIn the late 1970s, Marsha M. Linehan (1993) attempted to apply standard Cognitive Behavior Therapy (CBT) to the problems of adult women with histories of chronic suicide attempts, suicidal ideation, urges to self-harm, and self-mutilation. Slide13

DBT: OriginsClients receiving CBT found the unrelenting focus on change inherent to CBT invalidating

Clients unintentionally positively reinforced their therapists for ineffective treatment while punishing their therapists for effective therapyThe sheer volume and severity of problems presented by clients made it impossible to use the standard CBT formatSlide14

Cognitive behavioral treatment program developed to treat suicidal clients meeting criteria for Borderline Personality Disorder (BPD)Directly targets: suicidal behavior, behaviors that interfere with treatment delivery and other dangerous, severe or destabilizing behaviorsLinehan developed DBT from: restructuring CBT strategies to incorporate acceptance and change with dialectical strategies

Definition: DBTSlide15

Behavioral principles and techniques (CBT), attitude of acceptance embodied in validation, empathy and radical acceptance with relentless focus on problem solvingBiosocial Theory regarding BPDCentral Problem: emotional dysregulation

Emotional regulation is seen as having originated in and as being maintained by a lifelong mutually shaping transaction between a vulnerable temperament and an invalidating environment which leads to deficient emotion modulation skills and motivational problems

DBT: Underlying TheoryTheory

Slide16

A behavioral, problem-solving focus blended with acceptance-based strategies Emphasis on behaviorally explicit targets and treatment strategy groupsEmphasis on dialectical processes

DBT: Major CharacteristicsSlide17

Increase behavioral capabilitiesImprove motivation for skillful behavior (through contingency management and reduction of interfering emotions and cognitions)Assuring generalization of gains to natural environment

Structure the treatment environment so that it reinforces functional rather than dysfunctional behaviorsEnhance therapist capabilities and motivation to treat patients effectively

DBT: Addresses 5 functionsSlide18

Weekly individual psychotherapy (1hr/wk)Group skills training (2.5 hrs/wk)

Telephone consultationWeekly therapist consultation team meetings (to enhance therapist motivation and skills to provide therapy for the therapists)

1st four sessions are orientationFull protocol is two 6-month rounds of group therapy skills training

DBT: Protocol Slide19

Stage I: decreasing life threatening behaviors, behaviors that interfere with therapy, quality of life threatening behaviors and increasing skills that will replace ineffective coping behaviors. Stage II: addresses the client’s inhibited emotional experiencing. It is thought that the client’s behavior is now under control but the client is suffering “in silence

” Stage III: focuses on problems in living, with the goal being that the client has a life of ordinary happiness and unhappinessStage IV:

the goal of is for the client to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and freedom.

DBT: StagesSlide20

Core Mindfulness Skills: Skills to help one experience more fully the present momentDistress Tolerance: Cope better with painful events by building up resiliency and using new ways to soften the effects of upsetting circumstancesEmotion Regulation Skills: Help one recognize more clearly what they feel and then to observe each emotion without getting overwhelmed by it

Interpersonal effectiveness: New tools to express beliefs and needs, set limits and negotiate solutions to problemsCrisis Planning

DBT: Group Skills TrainingSlide21

Why DBT? Effective in treating suicidal ideations and attempts, self-injurious behaviors, compliance with treatment and problems in daily living activities

Associated with better treatment outcomes than treatment as usualLess likely to drop out, require less hospitalization for si, lower medical risk, fewer psychiatric hospitalizations and psychiatric emergency department visitsSlide22

Why DBT with PTSD treatment?DBT with PE has been found to reduce severe and chronic PTSD symptoms

DBT may protect against attritionPromotes coping skills for symptoms of trauma treatment (i.e. anxiety, fear, shame, anger, etc.)Promotes safety plan development and problem solving for floodingSlide23

Why DBT for Veterans with PTSD?Structures mindfulness practiceAddresses internal dissonanceRadical acceptance

Distress toleranceEmotion regulationSlide24

DBT with Veterans: ChallengesFailed to demonstrate superiority when compared to other treatmentsEvidenced based practice?Not validated as a supplement for PTSD treatment

Abstract concept of mindfulnessResistance to expressionSlide25

Integrating DBT with PEBecker and Zayfert (2001)

Skills training is integrated with individual therapyDuration is 5-16 weeks

Not participating in the larger DBT programPurpose is to prepare an individual to cope with any flooding issues prior to implementing the therapy

Integration can occur at any point during therapyServe to regulate emotions, tolerate distress and manage any suicidal impulsesSlide26

ReferencesAvailable Upon Request:

elizmorgan33@yahoo.com