challenges in war and at home steve scruggs, psy.d. oef/oif readjustment program team leader...
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Challenges in War and At Challenges in War and At HomeHome
Steve Scruggs, Psy.D.Steve Scruggs, Psy.D.OEF/OIF Readjustment ProgramOEF/OIF Readjustment Program
Team LeaderTeam LeaderOklahoma City VA Medical CenterOklahoma City VA Medical Center
Volunteer Clinical Assistant Volunteer Clinical Assistant Professor, OUHSCProfessor, OUHSC
OverviewOverview
Military cultureMilitary culture The making of a WarriorThe making of a Warrior Realities of combatRealities of combat Readjustment problemsReadjustment problems Successful transitionSuccessful transition
What Is Cultural Competency?
Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations.
US Dept of Health and Human Services, Office of Minority Health
Culture/CompetenceCulture/Competence
Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.
Competence implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities. (Adapted from Cross, 1989).
What does military culture What does military culture value?value?
ObedienceObedience DisciplineDiscipline Structure (including hierarchy)Structure (including hierarchy) Toughness (mental and physical)Toughness (mental and physical) Training/Following SOPs (standard operating Training/Following SOPs (standard operating
procedures)procedures) Completing the mission regardless of Completing the mission regardless of
hardshipshardships Up or outUp or out
Why do people join?Why do people join?
IdealisticIdealistic
I want to serve my I want to serve my country.country.
I want to defend I want to defend America.America.
I want to lead people in I want to lead people in battle.battle.
I want to be the best I I want to be the best I can be.can be.
I want to test myself.I want to test myself.
PracticalPractical
I’m not ready for college-I’m not ready for college-don’t know. what I want don’t know. what I want to do.to do.
I want college money.I want college money.
I want to learn a skill.I want to learn a skill.
I was homeless and had I was homeless and had no where to go.no where to go.
I thought it would help I thought it would help me shape up.me shape up.
Enlisted/OfficerEnlisted/Officer
85%85%E-1-3 Worker E-1-3 Worker E-4 JourneymanE-4 JourneymanNon-Commissioned Non-Commissioned Officers (NCO)Officers (NCO)E-5-6 Mid LevelE-5-6 Mid LevelE-7-8 Senior NCOE-7-8 Senior NCOE-9 Top 1%E-9 Top 1%
15%15%O-1-2 PlatoonO-1-2 PlatoonO-3 CompanyO-3 CompanyO-4-5 Mid levelO-4-5 Mid levelO-6+ Senior leaderO-6+ Senior leader
Warrant Officers 1-4Warrant Officers 1-4
Preparation for warPreparation for war
Intention exposure to stress, in a gradual, Intention exposure to stress, in a gradual, planned wayplanned way
High expectations/commitment requiredHigh expectations/commitment required Training to promote “muscle memory”Training to promote “muscle memory” Expectation is “You are going to war"Expectation is “You are going to war" The mission is worth risking your life for…The mission is worth risking your life for…
The Role of AggressionThe Role of Aggression When faced with a threat (fight/flight)When faced with a threat (fight/flight)
FIGHT!FIGHT! Starts the first day of basic trainingStarts the first day of basic training Used by role models (Drill Instructors, leaders)Used by role models (Drill Instructors, leaders) Used to “motivate” troopsUsed to “motivate” troops Learn to either shut up and do what you are Learn to either shut up and do what you are
told or get in someone’s facetold or get in someone’s face Go immediately to aggression if any “push Go immediately to aggression if any “push
back”back”
The Development of a WarriorThe Development of a Warrior
Basic trainingBasic training Military Occupation Specialty (MOS) Military Occupation Specialty (MOS)
training (AIT, Tech School)training (AIT, Tech School) Assignment to a unitAssignment to a unit Learning the job in the “real” militaryLearning the job in the “real” military Pre-deployment training, with increased Pre-deployment training, with increased
work hours and higher expectationswork hours and higher expectations DeploymentDeployment
Realities of CombatRealities of Combat Long hoursLong hours Constant vigilance (no battle lines to get behind)Constant vigilance (no battle lines to get behind) The enemy intentionally seeks to disrupt The enemy intentionally seeks to disrupt
(mortars at night, during chow)(mortars at night, during chow) Mission may be unclear (occupying force)Mission may be unclear (occupying force) Ambiguous situations are common (friend or Ambiguous situations are common (friend or
foe?)foe?) Rules of Engagement (ROEs) may change Rules of Engagement (ROEs) may change
arbitrarilyarbitrarily
A Soldier’s PerspectiveA Soldier’s Perspective
Constantly guarded, watchful and alertConstantly guarded, watchful and alert Wired and tiredWired and tired Increasingly gruff, impatientIncreasingly gruff, impatient Strong ties, strong dislikesStrong ties, strong dislikes Worry about home or emotional distancingWorry about home or emotional distancing Emotional numbingEmotional numbing
Do your job no matter what happensDo your job no matter what happens ““Shut up and drive on…”Shut up and drive on…”
Realities of CombatRealities of Combat
When a traumatic event occurs, the When a traumatic event occurs, the mission is still the prioritymission is still the priority
Processing emotions related to traumatic Processing emotions related to traumatic events is often delayed or avoidedevents is often delayed or avoided
Numbing of emotions is adaptive (short Numbing of emotions is adaptive (short term)term)
Distancing from others is adaptive (short Distancing from others is adaptive (short term)term)
A Soldier’s Perspective…A Soldier’s Perspective…
Often, there is a disillusionment of:Often, there is a disillusionment of:
ExperienceExperience
Military organization/LeadershipMilitary organization/Leadership
SelfSelf
Change in OutlookChange in Outlook
Changes are life savingChanges are life saving Changes become “the new normal”Changes become “the new normal” Changes may be celebratedChanges may be celebrated
I need this to be safeI need this to be safe Civilians are unprepared, stupid, naïveCivilians are unprepared, stupid, naïve
Reinforcing information is paid attention to Reinforcing information is paid attention to or even sought out (news of drive by or even sought out (news of drive by shooting, home invasions, robberies, mass shooting, home invasions, robberies, mass shootings, etc.)shootings, etc.)
Return/ReunionReturn/Reunion
Honeymoon phaseHoneymoon phase Disappointment due to problems or unmet Disappointment due to problems or unmet
expectationsexpectations Others expect the soldier to quickly return to Others expect the soldier to quickly return to
“normal”“normal” Frustration buildsFrustration builds Expression of anger is more intense and not Expression of anger is more intense and not
acceptable (like it was in theater of combat)acceptable (like it was in theater of combat)
Common Readjustment IssuesCommon Readjustment Issues
Problems getting Problems getting and staying asleepand staying asleep
Occasional Occasional nightmaresnightmares
Constantly alert Constantly alert and guardedand guarded
Uncomfortable in Uncomfortable in crowded placescrowded places
More gruff, irritableMore gruff, irritable
More goal oriented More goal oriented (have problems (have problems relaxing)relaxing)
Thinking about Thinking about combat combat experiences (even experiences (even when you don’t when you don’t want to)want to)
Why do sleep problems develop after combat and trauma? (Dr Rob Braese)
Unhealthy or erratic sleep patterns Night shift, long missions
Reinforcement Poor sleep is often rewarded (when you are
alert and sleep light you feel safer) Good, sound sleep is often punished
(attacks at night often make people feel vulnerable)
Why do sleep problems develop after combat and trauma?
New sleep habits More caffeine, drinking to fall asleep
Physical changes following deployment Pain and injuries make it hard to sleep
Mental changes following deployment Feeling "on edge“ Have to do a perimeter check if woken
Transition DifficultiesTransition Difficulties Continuously training Continuously training
for warfor war Routine/StructureRoutine/Structure
Constant vigilance Constant vigilance
Constantly “hitting the Constantly “hitting the gas”gas”
When faced with When faced with fight/flight-FIGHTfight/flight-FIGHT
Little training for peaceLittle training for peace No routine, no external No routine, no external
structurestructure Increased perception Increased perception
of threatof threat No strategies to “hit No strategies to “hit
the brakes”the brakes” Reactions scare Reactions scare
othersothers
Differences with members of Differences with members of National Guard & ReservistsNational Guard & Reservists
Many have established families and Many have established families and careers (that get disrupted by careers (that get disrupted by deployment)deployment)
Families do not live on military bases Families do not live on military bases (with support)(with support)
Do not have regular contact with fellow Do not have regular contact with fellow soldiers after return (limited support soldiers after return (limited support system)system)
Substance AbuseSubstance AbuseSeal et al. (2011)Seal et al. (2011) Drug and Alcohol Dependence Drug and Alcohol Dependence
About 1 in 10 had an alcohol use disorder and About 1 in 10 had an alcohol use disorder and 1 in 20 had a drug use disorder1 in 20 had a drug use disorder
Risk Factors: Risk Factors: Male sex, age under 25, never-married or divorced Male sex, age under 25, never-married or divorced status, and greater combat exposurestatus, and greater combat exposure
Almost 3/4 also received a diagnosis of PTSD Almost 3/4 also received a diagnosis of PTSD or depression. or depression.
Those with PTSD or depression were about 4x Those with PTSD or depression were about 4x more likely to have a drug or alcohol problem. more likely to have a drug or alcohol problem.
Close to those seen in Vietnam Veterans.Close to those seen in Vietnam Veterans.
Family ProblemsFamily Problems Sayers, Farrow, Ross & Olsin, 2009Sayers, Farrow, Ross & Olsin, 2009
Journal of Clinical PsychiatryJournal of Clinical Psychiatry
40.7% feeling like a guest in their house40.7% feeling like a guest in their house 25.0% children are not warm toward them 25.0% children are not warm toward them
or are afraid of themor are afraid of them 37.2% not sure of their family role37.2% not sure of their family role
Among separated partnersAmong separated partners 53.7% shouting, pushing or shoving53.7% shouting, pushing or shoving 27.6% partner is afraid of them27.6% partner is afraid of them
N=199N=199
Military Mindset/Academic MindsetMilitary Mindset/Academic Mindset
FunctionalFunctional Practical-Get er’ Practical-Get er’
DoneDone Subject ExpertSubject Expert Minimize DebateMinimize Debate Overcome Overcome
ObstaclesObstacles Accomplish the Accomplish the
Mission Mission
AbstractAbstract Thoughts and IdeasThoughts and Ideas Everyone’s opinionEveryone’s opinion Invite DiscussionInvite Discussion Discussion Discussion
Enhances Enhances Embrace the Embrace the
JourneyJourney
War Zones Require a Unique War Zones Require a Unique Set of Skills & Behaviors Set of Skills & Behaviors
James Monroe, Ed.D. Boston VAJames Monroe, Ed.D. Boston VA
WAR ZONE SKILLSWAR ZONE SKILLS Vigilance/DistrustVigilance/Distrust Chain of commandChain of command Mission OrientationMission Orientation
Act, then thinkAct, then think Numb or control Numb or control
emotions emotions Avoid closeness Avoid closeness
HOME SKILLSHOME SKILLS TrustTrust CooperationCooperation Juggling Multiple Juggling Multiple
ResponsibilitiesResponsibilities Think, then actThink, then act Express feelingsExpress feelings
Create intimacyCreate intimacy
Stress Injuries Occur When Stress Is Too Stress Injuries Occur When Stress Is Too Intense or Lasts Too LongIntense or Lasts Too Long CAPT W. Nash, USNCAPT W. Nash, USN
AdaptationAdaptation– A gradual processA gradual process– Can be traced over timeCan be traced over time– Individual remains in Individual remains in
controlcontrol– ReversibleReversible
InjuryInjury– May be more abruptMay be more abrupt– A derailment, change in selfA derailment, change in self– Individual loses controlIndividual loses control– Irreversible (though can heal)Irreversible (though can heal)
Three Mechanisms of Stress InjuryThree Mechanisms of Stress Injury
TRAUMATRAUMATRAUMATRAUMA
• An impact injury
• Due to events involving terror, horror, or helplessness
GRIEFGRIEFGRIEFGRIEF
• A loss injury• Due to the loss
of people who are cared about
FATIGUEFATIGUEFATIGUEFATIGUE
• A wear-and-tear injury
• Due to the accumulation of stress over time
COMBAT / OPERATIONAL COMBAT / OPERATIONAL STRESSSTRESS
COMBAT / OPERATIONAL COMBAT / OPERATIONAL STRESSSTRESS
Operational Stress Injuries Correlate Operational Stress Injuries Correlate with DSM-IV Diagnoseswith DSM-IV Diagnoses
Operational Stress Injuries Correlate Operational Stress Injuries Correlate with DSM-IV Diagnoseswith DSM-IV Diagnoses
TRAUMATRAUMATRAUMATRAUMA GRIEFGRIEFGRIEFGRIEFFATIGUEFATIGUEFATIGUEFATIGUE
Combat / Operational StressCombat / Operational StressCombat / Operational StressCombat / Operational Stress
PTSDPTSDPTSDPTSD
AlcoholAlcoholAlcoholAlcohol DrugsDrugsDrugsDrugs
DepressionDepressionDepressionDepression AnxietyAnxietyAnxietyAnxietyAngerAngerAngerAnger
Prepared by
Capt. William Nash, MC, USN
HQ, Marine Corps
Combat Stress PTSDCombat Stress PTSD Typical Reactions Mild/Moderate/SevereTypical Reactions Mild/Moderate/Severe to Combat Experiences to Combat Experiences
What Causes PTSD?What Causes PTSD?Risk FactorsRisk Factors
Intensity of trauma Intensity of trauma exposureexposure
Frequency of trauma Frequency of trauma exposureexposure
Killing Killing Prior traumatic eventsPrior traumatic events Combat verses Combat verses
Combat SupportCombat Support
Poor LeadershipPoor Leadership Lack of support Lack of support
(family, friends, etc.)(family, friends, etc.) Context/MeaningContext/Meaning Transition (military to Transition (military to
civilian life)civilian life) Avoidance of trauma Avoidance of trauma
related thoughts, related thoughts, memories or activitiesmemories or activities
What Causes PTSD?What Causes PTSD?Protective FactorsProtective Factors
TrainingTraining Experience Experience
(Habituation)(Habituation) Unit cohesion/ Unit cohesion/
leadershipleadership ExpectationsExpectations
Sense of purpose in Sense of purpose in suffering of self suffering of self and/or fellow service and/or fellow service membersmembers
Support on return Support on return ResilienceResilience
DSM-IV Criteria for Post Traumatic DSM-IV Criteria for Post Traumatic Stress Disorder (PTSD)?Stress Disorder (PTSD)?
Life threatening situation(s)Life threatening situation(s) Strong psychological reaction, e.g. intense Strong psychological reaction, e.g. intense
fear, helplessness, or horrorfear, helplessness, or horror
About 2/3 of combat veterans have at About 2/3 of combat veterans have at least one situation that was very least one situation that was very frightening, about 10-20% have PTSDfrightening, about 10-20% have PTSD
DSM-IV Criteria for PTSDDSM-IV Criteria for PTSD
DSM-5 Criteria ADSM-5 Criteria A
Exposure to actual or threatened death, Exposure to actual or threatened death, serious injury or sexual violation. The serious injury or sexual violation. The exposure to actual or threatened death, exposure to actual or threatened death, serious injury or sexual violence in one or serious injury or sexual violence in one or more of the ways:more of the ways:
DSM-5 Criterion ADSM-5 Criterion A
1.1. Directly experiencing the traumatic eventDirectly experiencing the traumatic event
2.2. Witnessing, in person, the event(s) as it Witnessing, in person, the event(s) as it occurred to othersoccurred to others
3.3. Learning that the traumatic event occurred to a Learning that the traumatic event occurred to a close family member or close friend. In cases close family member or close friend. In cases of actual or threatened death of a family of actual or threatened death of a family member or friend, the event(s) must have member or friend, the event(s) must have been violent or accidentalbeen violent or accidental
DSM-5 Criterion ADSM-5 Criterion A
4. Experiences repeated or extreme 4. Experiences repeated or extreme exposure to aversive details of the traumatic exposure to aversive details of the traumatic event(s) (e.g. first responders collecting event(s) (e.g. first responders collecting human remains; police officers repeatedly human remains; police officers repeatedly exposed to details of child abuse)exposed to details of child abuse)Note: Criterion 4A does not apply to Note: Criterion 4A does not apply to exposure through electronic media, exposure through electronic media, television, movies, or pictures, unless this television, movies, or pictures, unless this exposure is work-related)exposure is work-related)
DSM-5 Criteria for PTSDDSM-5 Criteria for PTSD
Four distinct diagnostic symptom clustersFour distinct diagnostic symptom clusters
Re-experiencingRe-experiencing AvoidanceAvoidance Negative cognitions and moodNegative cognitions and mood ArousalArousal
Re-experiencing symptomsRe-experiencing symptoms
Spontaneous memories of the traumatic Spontaneous memories of the traumatic eventevent
Recurrent dreams related to itRecurrent dreams related to it Flashbacks or other intense or prolonged Flashbacks or other intense or prolonged
psychological distresspsychological distress
Avoidance SymptomsAvoidance Symptoms
Avoidance refers to intentionally pushing Avoidance refers to intentionally pushing out of one’s mind:out of one’s mind: Distressing memoriesDistressing memories ThoughtsThoughts FeelingsFeelings Avoiding external reminders of the trauma. Avoiding external reminders of the trauma.
Negative Thinking and MoodNegative Thinking and Mood
Negative cognitions and mood represents Negative cognitions and mood represents myriad feelings:myriad feelings: Persistent and distorted sense of blame of Persistent and distorted sense of blame of
self or othersself or others Estrangement from othersEstrangement from others Markedly diminished interest in activitiesMarkedly diminished interest in activities (Less common) An inability to remember key (Less common) An inability to remember key
aspects of the event aspects of the event
Arousal SymptomsArousal Symptoms
Arousal is marked by:Arousal is marked by: Aggressive, reckless or self-destructive Aggressive, reckless or self-destructive
behaviorbehavior Sleep disturbancesSleep disturbances Hyper-vigilance or related problems. Hyper-vigilance or related problems.
Both “fight” and “flight” reactionsBoth “fight” and “flight” reactions
Mild TBI - PTSD: Mild TBI - PTSD: Overlapping Symptoms Overlapping Symptoms Scholten/CollinsScholten/Collins
Postconcussion Syndrome Postconcussion Syndrome (PCS)(PCS)
InsomniaInsomnia Memory ProblemsMemory Problems Poor concentrationPoor concentration DepressionDepression AnxietyAnxiety IrritabilityIrritability FatigueFatigue NoiseNoise//lightlight intoleranceintolerance DizzinessDizziness HeadacheHeadache
PTSDPTSD
InsomniaInsomnia Memory problemsMemory problems Poor concentrationPoor concentration DepressionDepression AnxietyAnxiety IrritabilityIrritability Re-experiencingRe-experiencing AvoidanceAvoidance Emotional numbingEmotional numbing
Successful RecoverySuccessful Recovery
Overcoming barriers to treatmentOvercoming barriers to treatment Assessing the problemAssessing the problem Normalizing reactionsNormalizing reactions Engaging in/Completing TreatmentEngaging in/Completing Treatment Aftercare, if neededAftercare, if needed
Barriers to treatmentBarriers to treatment
StigmaStigma Worry about impact on military or civilian Worry about impact on military or civilian
careercareer Worry about being seen as “crazy” or Worry about being seen as “crazy” or
“paranoid”“paranoid” Finding resourcesFinding resources Negotiating bureaucraciesNegotiating bureaucracies Getting to treatment (low wage jobs, no paid Getting to treatment (low wage jobs, no paid
time off)time off)
Assessing the problemAssessing the problem
Sometimes well meaning, caring people Sometimes well meaning, caring people can push a combat veteran to talk…can push a combat veteran to talk…
Triggers either fear and distance or Triggers either fear and distance or overexposure and feeling overwhelmedoverexposure and feeling overwhelmed
““I thought talking about it was going to I thought talking about it was going to make me feel better, but instead…”make me feel better, but instead…”
Normalizing reactionsNormalizing reactions
You are not crazyYou are not crazy It makes sense to be watchful, guarded and It makes sense to be watchful, guarded and
alert (You are not paranoid)alert (You are not paranoid) You developed skills to help you adapt to a You developed skills to help you adapt to a
difficult and dangerous environmentdifficult and dangerous environment These skills saved your life in war zone, so These skills saved your life in war zone, so
may seem essential to keepmay seem essential to keep These skills may not be working so well for These skills may not be working so well for
you nowyou now
Engaging in treatmentEngaging in treatment
This is often a big stepThis is often a big step Outcome research for substance abuse Outcome research for substance abuse
shows equal improvement whether self shows equal improvement whether self referred or “a nudge from the judge”referred or “a nudge from the judge”
Matching the person with a treatment that Matching the person with a treatment that is acceptable to them is key is acceptable to them is key
Treatment OptionsTreatment Options
Symptom ManagementSymptom Management More acceptable to More acceptable to
many veteransmany veterans Easy to “try out”Easy to “try out” Gives practical, “how Gives practical, “how
to” skills and fast to” skills and fast relief (e.g. with meds)relief (e.g. with meds)
Best approach for Best approach for limited symptoms limited symptoms (e.g. nightmares)(e.g. nightmares)
Trauma FocusedTrauma Focused Research strongly Research strongly
indicates best choice indicates best choice for improvement (with for improvement (with Evidenced-Based Evidenced-Based Psychotherapies)Psychotherapies)
SystematicSystematic Time limited (usually Time limited (usually
12-15 sessions)12-15 sessions)
Avoidance and TreatmentAvoidance and Treatment
Since avoidance is a symptom of PTSD, Since avoidance is a symptom of PTSD, the person will be tempted to cancel or not the person will be tempted to cancel or not show for sessionsshow for sessions
Completing treatment is difficult, especially Completing treatment is difficult, especially if engaged in trauma focused treatmentif engaged in trauma focused treatment
Free Self Help Treatment Free Self Help Treatment OptionsOptions
Afterdeployment.orgAfterdeployment.org Put together by the Dept of Defense and Put together by the Dept of Defense and
offers help for sleep, anger, PTSD, family offers help for sleep, anger, PTSD, family issues, etc.issues, etc.
Maketheconnection.netMaketheconnection.net Developed by the VA to help veterans Developed by the VA to help veterans
connect with other veterans from the same connect with other veterans from the same era with similar issues.era with similar issues.
Mobile App: PTSD Coach Mobile App: PTSD Coach ncptsd.govncptsd.gov
Learning Alternative Ways to Learning Alternative Ways to RespondRespond
Respond rather than react Respond rather than react Changing “muscle memory”Changing “muscle memory”
Learn assertive versus passive or Learn assertive versus passive or aggressive responsesaggressive responses
What makes reactions better or What makes reactions better or worse?worse?
Worse:Worse: Looking at situations Looking at situations
as if you are still in as if you are still in war zonewar zone
Insisting immediate Insisting immediate improvementimprovement
Assuming that all Assuming that all alarming reactions alarming reactions are “true alarms”are “true alarms”
Becoming a hermitBecoming a hermit
Better:Better: Reminding yourself you Reminding yourself you
are not in a war zoneare not in a war zone Staying in situations Staying in situations
long enough to allow long enough to allow the alarm reaction to the alarm reaction to go downgo down
Being around people Being around people even though it may feel even though it may feel awkward at firstawkward at first
Evidence-Based TherapiesEvidence-Based Therapies
Prolonged Exposure (PE) and Cognitive Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are treatments Processing Therapy (CPT) are treatments endorsed by the Veterans Administration endorsed by the Veterans Administration as evidence-based treatments for PTSD.as evidence-based treatments for PTSD.
EMDR is a promising treatment for PTSD. EMDR is a promising treatment for PTSD.
A Qualification (Hoge-2010)A Qualification (Hoge-2010)
Effect sizes Effect sizes Meds (59% recovery versus 39% placebo)Meds (59% recovery versus 39% placebo) Psychotherapy (41% Exposure Therapy Psychotherapy (41% Exposure Therapy
versus 29% Supportive (no specific)versus 29% Supportive (no specific) CPT 3 versus 40%CPT 3 versus 40% Partial versus Complete Recovery from Partial versus Complete Recovery from
PTSD may be the case for many veteransPTSD may be the case for many veterans
Prolonged Exposure (PE)Prolonged Exposure (PE)
PE is a 10-15 session program that is done in PE is a 10-15 session program that is done in 90 minute individual sessions. There is also 90 minute individual sessions. There is also considerable out of session “homework” considerable out of session “homework” involved. involved.
15+ Randomized Controlled Trials/Many 15+ Randomized Controlled Trials/Many “Effectiveness” studies“Effectiveness” studies
The Veteran monitors symptoms by completing The Veteran monitors symptoms by completing a symptom checklist (PCL-M).a symptom checklist (PCL-M).
www.ptsd.va.gov/public/pages/www.ptsd.va.gov/public/pages/prolongedprolonged--exposureexposure--therapytherapy.asp.asp
Prolonged Exposure (PE)Prolonged Exposure (PE)
PE is a treatment that helps survivors of PE is a treatment that helps survivors of trauma to emotionally process their trauma to emotionally process their experiences. experiences.
Veterans are helped to confront their trauma Veterans are helped to confront their trauma memory. This is done to decrease their fear and memory. This is done to decrease their fear and anxiety. An example of this is the rider that is anxiety. An example of this is the rider that is encouraged to “get back on the horse” after encouraged to “get back on the horse” after being thrown off. The rider overcomes the fear of being thrown off. The rider overcomes the fear of being thrown again. This also prevents the fear being thrown again. This also prevents the fear from affecting other areas of his life.from affecting other areas of his life.
PE – 2 main componentsPE – 2 main components
Imaginal exposure: Imaginal exposure: Client recounts Client recounts their worst traumatic event in detail their worst traumatic event in detail repeatedly in session (and daily listens to repeatedly in session (and daily listens to tapes of themselves out of session)tapes of themselves out of session)
In-vivo exposure: In-vivo exposure: Client develops a Client develops a hierarchy of avoided situations and exposes hierarchy of avoided situations and exposes themselves to these situations for 30-45 themselves to these situations for 30-45 minutes daily (starting with situations that minutes daily (starting with situations that are 30 on a 0-100 scale)are 30 on a 0-100 scale)
Resources for Therapist and Resources for Therapist and PatientPatient
Prolonged Exposure Therapy for PTSD: Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Emotional Processing of Traumatic Experiences Therapist Guide Experiences Therapist Guide (Treatments That (Treatments That Work) Work) Edna Foa, Elizabeth Hembree, Barbara Olaslov RothbaumEdna Foa, Elizabeth Hembree, Barbara Olaslov Rothbaum
Reclaiming Your Life from a Traumatic Reclaiming Your Life from a Traumatic Experience: A Prolonged Exposure Experience: A Prolonged Exposure Treatment Program Workbook (Treatments Treatment Program Workbook (Treatments That Work) That Work) Barbara Rothbaum, Edna Foa, Barbara Rothbaum, Edna Foa, Elizabeth HembreeElizabeth Hembree
PE app (ncptsd.gov) PE app (ncptsd.gov)
Center for Deployment PsychologyCourse 113 (Online): Cognitive Processing Therapy (CPT) for PTSD in Veterans and Military Personnel
National Center for PTSDThe Course Cognitive Behavioral Psychotherapies for PTSD outlines the components and empirical support for two evidence-based treatments: Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT).
Cognitive Processing Therapy Cognitive Processing Therapy (CPT)(CPT)
12 Session structured psychotherapy approach12 Session structured psychotherapy approach 7 Randomized Controlled Trials/Many 7 Randomized Controlled Trials/Many
“Effectiveness” studies“Effectiveness” studies Based on a social cognitive theory of PTSD that Based on a social cognitive theory of PTSD that
focuses on how the traumatic event(s) is construed focuses on how the traumatic event(s) is construed and coped with by a person who is trying to regain and coped with by a person who is trying to regain a sense of mastery and control in his/her lifea sense of mastery and control in his/her life
Based on the Cognitive Therapy Model developed Based on the Cognitive Therapy Model developed by Aaron Beck, M.D.by Aaron Beck, M.D.
Also utilizes therapeutic writing strategies Also utilizes therapeutic writing strategies developed by James Pennebaker, Ph.D.developed by James Pennebaker, Ph.D.
Cognitive Processing TherapyCognitive Processing Therapy
CPT is a 12 session program that can be CPT is a 12 session program that can be done in individual (much research basis) done in individual (much research basis) or group sessions (emerging research or group sessions (emerging research basis).basis).
There is also some out of session There is also some out of session “homework” involved-writing about the “homework” involved-writing about the trauma and writing about one’s thoughts trauma and writing about one’s thoughts and emotions. This is reviewed with the and emotions. This is reviewed with the therapist in session.therapist in session.
Cognitive Processing TherapyCognitive Processing Therapy(CPT)(CPT)
CPT begins with education about trauma. CPT begins with education about trauma. It looks at the normal reactions to the It looks at the normal reactions to the trauma. The therapy then moves to look trauma. The therapy then moves to look at and evaluate your thinking and beliefs at and evaluate your thinking and beliefs about the events. You are finally asked to about the events. You are finally asked to "talk" about your experiences by writing "talk" about your experiences by writing about them. You read them to the about them. You read them to the therapist (and/or group members). therapist (and/or group members).
CPTCPT
Reading about your trauma is followed by Reading about your trauma is followed by a discussion of "stuck points." Stuck a discussion of "stuck points." Stuck points are memories or thoughts you have points are memories or thoughts you have been unable to move past. They continue been unable to move past. They continue to impact on your ability to live a full life. to impact on your ability to live a full life. The Veteran monitors symptoms by The Veteran monitors symptoms by completing a check list (PCL-M). completing a check list (PCL-M).
Treatment Model: Cognitive Treatment Model: Cognitive Processing Therapy (CPT)Processing Therapy (CPT)
Focus on the Focus on the contentcontent of cognitions of cognitions and the effect that distorted cognitions and the effect that distorted cognitions have upon emotional responses and have upon emotional responses and behaviorbehavior
Sees PTSD as a disruption or stalling Sees PTSD as a disruption or stalling out of a normal recovery process – and out of a normal recovery process – and works to determined what interfered works to determined what interfered with normal recoverywith normal recovery
Eye Movement Desensitization and Eye Movement Desensitization and Reprocessing (EMDR)Reprocessing (EMDR)
EMDR is a treatment for traumatic EMDR is a treatment for traumatic memories that involves elements of memories that involves elements of exposure therapy and cognitive behavioral exposure therapy and cognitive behavioral therapy, combined with techniques like therapy, combined with techniques like eye movements or hand taps that cause eye movements or hand taps that cause the patient’s attention to alternate back the patient’s attention to alternate back and forth across the midline. and forth across the midline.
EMDR Outcome StudiesEMDR Outcome Studies
EMDR has been shown to be more EMDR has been shown to be more effective than placebo wait list, effective than placebo wait list, psychodynamic, relaxation, or supportive psychodynamic, relaxation, or supportive therapies. However, research comparing therapies. However, research comparing EMDR to other CBT therapies shows EMDR to other CBT therapies shows significantly better results have been significantly better results have been maintained with CBT than EMDR, maintained with CBT than EMDR, particularly over time.particularly over time.
AftercareAftercare
Many veterans will benefit from ongoing Many veterans will benefit from ongoing supportsupport
This can be community based or may be This can be community based or may be part of a formal mental health treatment part of a formal mental health treatment programprogram
OEF/OIF/OND Readjustment ProgramOEF/OIF/OND Readjustment Program(405) 456-2855(405) 456-2855
Carly Hobbs, Program Support AssistantCarly Hobbs, Program Support Assistant
Yan Feng, M.D., Medical DirectorYan Feng, M.D., Medical Director
Gina Pierce, M.D., PsychiatristGina Pierce, M.D., Psychiatrist
Shannon Thomas, M.D., PsychiatristShannon Thomas, M.D., Psychiatrist
Steve Scruggs, Psy.D., Team LeaderSteve Scruggs, Psy.D., Team Leader
[email protected]@va.gov
Susan Shead, LCSW, Social WorkerSusan Shead, LCSW, Social Worker
Amber Ward, LCSW, Social WorkerAmber Ward, LCSW, Social Worker
Rob Braese, Ph.D., Staff PsychologistRob Braese, Ph.D., Staff Psychologist
Anna Colston, PA-C, Physician AssistantAnna Colston, PA-C, Physician Assistant
Regan Settles, Ph.D., Postdoctoral Fellow Regan Settles, Ph.D., Postdoctoral Fellow