CHALLENGES TO TREATMENT - Mental Health America of Wisconsin

Report
CHALLENGES to
TREATMENT of
COMBAT PTSD
John Mundt, Ph.D.
[email protected]
www.drjohnmundt.com
CHALLENGES TO TREATMENT
Cultural / subcultural considerations
MILITARY CULTURE
 Importance of group over individual
 “What happens in the bush, stays in the bush”
 “Machismo”
 Issues re: authority
GENERATIONAL
 Young adults
vs reservists
ETHNICITY/NATIONAL ORIGIN
 Culturally appropriate emotional expression
CHALLENGES TO TREATMENT
Other Mental Health Problems
Pre-existing Trauma
Common Therapist Error: failure to assess for other
trauma
Can be from many non-military sources: childhood
abuse, traumatic loss, correctional system, addiction
Discrete trauma (rape, natural disaster) vs. prolonged or
repeated
Multi-layered trauma: complex, more difficult to treat
CHALLENGES TO TREATMENT
Other Mental Health Problems
“Personality Disorders”: Problem of diagnosis and nomenclature
Controversial use of Character Disorder diagnoses by
military
“Cluster B” personality traits: overlap with concept of
multiple layers of trauma
Continuum of trauma-based disorders: PTSD, BPD, DID
are all possible responses to stress and trauma
 “Personality Disorder” can both increase and decrease
likelihood of “PTSD”
CHALLENGES TO TREATMENT
Other Mental Health Problems
Other Axis I psychiatric illness
 Typical onset age for chronic mental illness coincides with
military service
 Diathesis-Stress Model: warzone deployment is the stress
 Risk of assuming PTSD in all OEF/OIF veterans presenting for
treatment
 Assess family history of mental illness/psychiatric treatment
TRAUMATIC BRAIN INJURY (TBI)
TRAUMATIC BRAIN INJURY (TBI)
“Signature Injury” of this war
• Explosions account for 3 of 4 combat-related injuries 1
• Use of IED’s in Afghanistan and Iraq
• Improvements in warzone trauma treatment decrease
fatalities
• Exposure to toxins, other causes of brain injury
Zouris,J.M., Walker, G.J., Dye, J. & Galarnewau, M. (2006). Wounding
patterns for U.S. Marines and sailors during Operation Iraqi Freedom,
major combat phase. Military Medicine, 171(3):246-52.
1
CHALLENGES TO TREATMENT
ADDICTION and SUBSTANCE ABUSE
 Alcohol, cocaine and methamphetamine
were available in Iraq
Afghanistan is world’s largest producer of opium
Many medically injured troops are prescribed
painkillers
VA: 10%+ increase in veterans seeking drug
treatment since start of war
Significant impediment to treatment of OEF/OIF
veterans with PTSD
Lessons from Vietnam veterans
ADDICTION and SUBSTANCE ABUSE
Factors leading to substance abuse problems:
 Pre-existing problems
 “Self-medication” of depression, PTSD
 Chronic pain
 Boredom
 Affiliation/ peer pressure: culture
Pre-existing substance use/abuse
“Self-medication”
Anxiety and hypervigilance
Insomnia
Depression
Anger and volatility
CHRONIC PAIN
Intractable pain as a chronic stressor
Physical demands of military deployment: “Battle rattle”
Headaches: PTSD versus TBI versus other medical basis
Orthopedic, neurological, psychosomatic
Medication of “pain”: physical versus emotional
Boredom/ isolation/ avoidance
Culture of drinking
CHALLENGES TO TREATMENT
ADDICTION and SUBSTANCE ABUSE
DAY HOSPITAL PROGRAM approach:
 Detailed assessment
Psychoeducation: - use vs. abuse vs. dependence
-abuse = impairments in functioning
(emotional, vocational, social, physical)
 Emphasis on honesty over total abstinence
Lapses are a part of recovery: lapses are not relapses, but
may lead to them
Continued abuse: progressive “tightening of the reins”
(Dual Diagnosis engagement groups for combat veterans)
Caveats: dangerous use, clear-cut dependence, historical
treatment failures
CHALLENGES TO TREATMENT
ADDICTION and SUBSTANCE ABUSE
Dangers of extremes in therapist stance:
TOO PERMISSIVE:
 Failure to benefit from treatment
 Intoxication, self-medicating as end-point of abreaction
 Therapist frustration
TOO RIGID:
 Withdrawal from treatment
 Contraindications of formal addictions programs
CHALLENGES TO TREATMENT : SUICIDE
Lessons from Vietnam
CHALLENGES TO TREATMENT : SUICIDE
Literature: Both trauma exposure
and specific diagnosis of PTSD are linked
with suicidal behavior. Why?
Despair
 Impulsivity
Guilt / Grief
 “Misadventure”
CHALLENGES TO TREATMENT : SUICIDE
High-profile suicides of OEF/OIF veterans
have led to changes in VA policy/approach:
• Suicide hotline
(National Suicide Prevention
Lifeline: Call
1-800-273-TALK (8255),
and press “1” to be connected to
VA hotline)
• Suicide Prevention Coordinators
• Increased outreach and follow-up
CHALLENGES TO TREATMENT :
SUICIDE
ASSESSING RISK: Patterson et al’s “SAD PERSONS” mnenomic:
S ex (male)
A ge (elderly or adolescent)
D epression
P revious suicide attempts (highest risk within 3 months of prior
attempt)
E thanol abuse (alcoholics’ rate of suicide is 50x that of non-alcoholics)
R ational thinking loss (psychosis)
S ocial supports lacking (subjective perception of lack)
O rganized plan to commit suicide (specific, lethal)
N o spouse (divorced > widowed > single)
S ickness (physical illness)
Patterson WM, Dohn HH, Bird J, et al. Evaluation of suicidal patients: the
SAD PERSONS scale. Psychosomatics 1983;24(4):343-9
CHALLENGES TO TREATMENT :
SUICIDE
ASSESSING RISK: Suicide warning signs in veterans
o CHANGE in behavior
o Calling friends, particularly vets, to say goodbye
o Cleaning weapons
o Visiting graveyards
o Stopping or hoarding medication, alcohol
o Spending sprees, buying gifts
o Obsession with media coverage of war
o Wearing uniform, combat gear
CHALLENGES TO TREATMENT :
SUICIDE
WEAPONS and OEF/OIF veterans
“Don’t leave home without it!”
CHALLENGES TO TREATMENT :
SUICIDE
GENERAL CONSIDERATIONS with OEF/OIF veterans
 Efficacy of no-suicide contracts
 Importance of ongoing assessment during trauma
therapy
 Crisis Intervention: plan ahead
CHALLENGES TO TREATMENT :
VIOLENCE
ASSESSMENT: Should be specific
 Impulsive/reactive (in context of hyperarousal?
Dissociation?) AFFECTIVE VIOLENCE
 Planned/deliberate (starting
fights? “patrolling”?) PREDATORY VIOLENCE
 Domestic violence
 Intoxication (disinhibition?)
 Related to peer-group
 “Suicide by cop”
CHALLENGES TO TREATMENT :
VIOLENCE
WEAPONS
PARANOIA
STIMULANTS
Common “points of contact”
for vets with legal system:
 Substance abuse (DUI/DWI; intoxication)
 Aggression and violence (DV; workplace;
public fights)
 Suicidal behavior
 Driving offenses
 Weapons
 “disorderly”: crowds, authorities
CHALLENGES TO TREATMENT
HOSPITALIZATION

Should be brief if possible
 Initial experience may determine future
compliance in emergency situations
 Acute versus planned (specific programs)
CHALLENGES TO TREATMENT
Confronting AMBIVALENCE

TRAUMA is about loss of power and control
Psychoeducation should be ongoing: joint
perusal of a roadmap
Flexibility in “closing cases”: “diminishing
orbits” concept
CHALLENGES TO TREATMENT
MALINGERING
 Politics of PTSD and disability benefits:
"We have young men and women coming back from Iraq who
are having PTSD and getting the message that this is a
disorder they can't be treated for, and they will have to be on
disability for the rest of their lives. My concern about the
policies is that they create perverse incentives to stay ill. It is
very tough to get better when you are trying to demonstrate
how ill you are.“
 Process of assessment should include questions re: claims,
benefits
 Detecting/confronting malingering is at odds with usual
therapist stance
CHALLENGES TO TREATMENT
DETECTION of MALINGERING
Assess for secondary gain (VA claims, lawsuits)
Psychometric measures (both specific to PTSD, and
general like MMPI-2)
Presentation of client: “every symptom in the book”
Traumatic material: no distress upon exploration OR
total avoidance
Traumatic material: inconsistent with probable
experience
Benefit of therapy groups
COMMON THERAPIST ERRORS
1) Premature focus on trauma processing
2) Avoidance of trauma processing
3) Projection of therapist’s beliefs and values about
military experience
4) Projection of therapist’s assumptions about what is and
what is not traumatic
5) Inadequate assessment of trauma history
COMMON THERAPIST ERRORS
1) Premature focus on trauma processing: “Get it all out”
Can lead to:
• Frightening dissociation
• Suicidal or violent behavior
• Withdrawal from treatment
• Abreaction
ABREACTION: Intense reliving of the trauma
• Freud (1892) used hypnosis to facilitate
• Long considered an important part of trauma therapy
• Technique or
adverse effect?
copyright Mundt 2012
ABREACTION as a goal of therapy:
• “Lancing a boil”
• Bennett Braun’s BASK theory:
• Dissociative client needs to re-experience
behavior, affect, sensation, knowledge
• (Braun, B.G. (1988) BASK Model of
Dissociation, Part I. Dissociation, 1:1, 4-23)
ABREACTION as an adverse effect:
• Painful and intense: somatic memories
• Dangerous behavior during dissociation
• Persists beyond session
ABREACTION:
“The abreaction of intense affect is not a goal of
psychotherapy; it is an inevitable concomitant experience in
the therapy of persons with post-traumatic histories,
physical and/or sexual abuse, neglect, and related innate
experiences.”
Chefetz, R.A. Abreaction: Baby or Bathwater. Dissociation
Vol.X, No.4, 12/97
Managing ABREACTION:
• Maintain a calm demeanor
• Consider your tolerance for extremity and for
strong affect
• Safety considerations
• Consider both timing and pacing of sessions
COMMON THERAPIST ERRORS
2) Avoidance of trauma processing can lead to:
•
•
•
•
Worsening of symptoms and related behavior
Increased subjective pressure to “self-medicate”
Entrenching maladaptive coping responses
Withdrawal from treatment
COMMON THERAPIST ERRORS
3) Projection of therapist’s beliefs and values about military
experience
• Do a “self-assessment” as to your own views of the war,
your assumptions about the military, about soldiers
• Consider the source of your beliefs and assumptions
COMMON THERAPIST ERRORS
4) Projection of therapist’s assumptions about what is and
what is not traumatic
• Importance of assessment not just of experiences, but of
client’s PERCEPTION of those experiences
• Avoid “loaded” words like traumatic: Ask “what was
hardest for you?”
• Maintain awareness of triggers/stressors unique to
OEF/OIF experience (i.e., Arab-appearing
clinicians/staff)
• Be alert for vicarious traumatization
(“PTSD by proxy”)
COMMON THERAPIST ERRORS
5) Failure to assess for “layers” of trauma
• Assessment should include childhood and other noncombat trauma
• Consider possible causes of failure to disclose
(subjectively “unsafe”, security clearances, classified
“black ops”)
10 things to do in Session #1 !
#1: PRAISE the client
#2: VALIDATE their experience
#3: EDUCATE about pacing and timing
#4: PREDICT the course of treatment
#5: ACCEPT the inappropriate
#6: EXPLAIN parameters of sessions
#7: WARN about worsening of symptoms
#8: EMPLOY analogies liberally
#9: OFFER human touch
#10: GIVE something to read
10 things to do in Session #1 !
#1: PRAISE the client
Reinforce their decision to start this process
-Acknowledge the difficulty in this, the stigma, the risk
-Express optimism
-
10 things to do in Session #1 !
#2: VALIDATE their Experience
-Normalize post-Traumatic reactions
-De-pathologize PTSD symptoms
10 things to do in Session #1 !
#3: EDUCATE about timing & Pacing
-Ask about previous experience of flooding
-Want to avoid “Overdosing”
10 things to do in Session #1 !
#4: PREDICT the course of therapy
-Educate about your model
-Estimate length/duration
10
things to do in Session #1 !
#5: ACCEPT the inappropriate
-”Gallows” humor
-Extreme views, statements
-Prejudices, profanity
10
things to do in Session #1 !
#6: Explain parameters
-”housekeeping”
-Crisis procedures,
availability
10
things to do in Session #1 !
#7: Warn about worsening symptoms
-important caveat
-”Stirring the mud in the puddle”
10 things to do in Session #1 !
#8: Employ analogies liberally!
-Process of turning an 18-wheeler around
-Hurricane reporters
-veterans: basic training drills
-bowel/bladder analogies
10
things to do in Session #1 !
#9: Offer human touch
-only if indicated
-can be grounding or alarming
10
things to do in Session #1 !
#10: Give something to read
-pamphlets
-reading list
-websites
[email protected]
www.drjohnmundt.com

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