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Psychotherapeutic Treatment of Appalachian Combat Veterans with PTSD Myra Qualls Elder, Ph.D. James H. Quillen Veterans Affairs Medical Center, Mountain.

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Presentation on theme: "Psychotherapeutic Treatment of Appalachian Combat Veterans with PTSD Myra Qualls Elder, Ph.D. James H. Quillen Veterans Affairs Medical Center, Mountain."— Presentation transcript:

1 Psychotherapeutic Treatment of Appalachian Combat Veterans with PTSD Myra Qualls Elder, Ph.D. James H. Quillen Veterans Affairs Medical Center, Mountain Home, TN

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3 Post Traumatic Stress Disorder Trauma: Outside normal range of human experience Trauma: Outside normal range of human experience Re-experiencing the trauma: Re-experiencing the trauma: –Nightmares –Intrusive memories –Flashbacks –Distress when faced with triggers

4 PTSD Symptoms: Avoidance Avoidance of thoughts, feelings, people, places assoc. w/ the trauma Avoidance of thoughts, feelings, people, places assoc. w/ the trauma Detachment/numbing/estrangement Detachment/numbing/estrangement Some amnesia of trauma Some amnesia of trauma Foreshortened future Foreshortened future Loss of interest in activities Loss of interest in activities

5 PTSD Symptoms: Arousal Insomnia/broken sleep Insomnia/broken sleep Irritability/anger Irritability/anger Problems concentrating Problems concentrating Hypervigilance Hypervigilance Exaggerated startle response Exaggerated startle response Symptoms listed in DSM-IV-TR

6 Proposed Changes To PTSD Diagnosis in DSM-V (2013) Event experienced by close relative/friend Event experienced by close relative/friend Do not need to feel fear/helplessness/horror Do not need to feel fear/helplessness/horror Repeated exposure to distressing details of events of others (police officer, for ex.) Repeated exposure to distressing details of events of others (police officer, for ex.) Criterion D: negative thoughts, moods, or evaluations of self and/or world Criterion D: negative thoughts, moods, or evaluations of self and/or world (Thanks to Dr. Tom Stoss for this information) (Thanks to Dr. Tom Stoss for this information)

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8 Appalachian Veteran-Specific Diagnostic Questions When do you do your grocery shopping? When do you do your grocery shopping? Do you ever eat at a restaurant? Where do you sit? Do you ever eat at a restaurant? Where do you sit? Is there a gun in your bedroom? How many guns are in your house? Is there a gun in your bedroom? How many guns are in your house? How many times a night do you check your window/door locks? How many times a night do you check your window/door locks? What do you do on July 4 th ? What do you do on July 4 th ?

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10 PTSD Prevalence Data Community stats: current PTSD rates = 5-6% men, 10-12% women Community stats: current PTSD rates = 5-6% men, 10-12% women National Vietnam Veterans Readjustment Study (mid-1980s): then-current PTSD rates = 15% men, 8% women National Vietnam Veterans Readjustment Study (mid-1980s): then-current PTSD rates = 15% men, 8% women Lifetime rates: 30% men, 25% women (cited in Friedman, 2004) Lifetime rates: 30% men, 25% women (cited in Friedman, 2004)

11 PTSD Prevalence Data II Operation OIF/OEF: 2008 Rand Institute Study: 18.5% diagnosed with PTSD Operation OIF/OEF: 2008 Rand Institute Study: 18.5% diagnosed with PTSD 35% of Iraq war vets accessed MH svcs in the year after returning home (Hoge, et al., 2006) 35% of Iraq war vets accessed MH svcs in the year after returning home (Hoge, et al., 2006) 2001-2005, N = 103,788 OEF/OIF vets: 2001-2005, N = 103,788 OEF/OIF vets: 25% received MH dxs, 56% of those rec’d 25% received MH dxs, 56% of those rec’d 2 MH dxs, skewed toward vets 18-24 (Seal, et al., 2007) 2 MH dxs, skewed toward vets 18-24 (Seal, et al., 2007)

12 National Center for PTSD Data 12% to 20% soldiers and Marines had PTSD after serving in Iraq 12% to 20% soldiers and Marines had PTSD after serving in Iraq 7% to 15% had depression after serving in Iraq or Afghanistan 7% to 15% had depression after serving in Iraq or Afghanistan 1 in every 4 soldiers or Marines reported using alcohol more than they meant to 1 in every 4 soldiers or Marines reported using alcohol more than they meant to 1 of every 3 returning soldiers treated by the VA for MH issues 1 of every 3 returning soldiers treated by the VA for MH issues

13 Now what? Establish trust: necessary condition Establish trust: necessary condition Must be present: minimize distraction, pay attention, have two channels open Must be present: minimize distraction, pay attention, have two channels open Must be engaged: reflective is good, responsive is better, avoid being reactive Must be engaged: reflective is good, responsive is better, avoid being reactive Patient must feel as safe as possible, physically and emotionally (ex. windows, pagers, intrusions) Patient must feel as safe as possible, physically and emotionally (ex. windows, pagers, intrusions)

14 Conditions Necessary for Tx Time: no substitute for this, need it for trust to develop Time: no substitute for this, need it for trust to develop Maslow’s Triad: can it be taught? Maslow’s Triad: can it be taught? Culture/Context: military training, masculinity, Appalachian (“Alvin York Syndrome”) Culture/Context: military training, masculinity, Appalachian (“Alvin York Syndrome”) Military service an honorable way to individuate from an enmeshed family Military service an honorable way to individuate from an enmeshed family

15 From Sebastian Junger’s 2010 book, “War,” about the 173 rd in Afghanistan “War is supposed to feel bad because undeniably bad things happen in it, but for a 19-y.o. at the working end of a.50 cal during a firefight that everyone comes out of okay, war is life multiplied by some number that no one has ever heard of. In some ways, 20min of combat is more life than you could scrape together in a lifetime of doing something else.” “War is supposed to feel bad because undeniably bad things happen in it, but for a 19-y.o. at the working end of a.50 cal during a firefight that everyone comes out of okay, war is life multiplied by some number that no one has ever heard of. In some ways, 20min of combat is more life than you could scrape together in a lifetime of doing something else.”

16 Early Therapeutic Tasks Orientation to therapy Orientation to therapy Rationale for therapy: “crude oil to gasoline” and reducing avoidance Rationale for therapy: “crude oil to gasoline” and reducing avoidance Possible negative and positive effects of therapy (this is informed consent) Possible negative and positive effects of therapy (this is informed consent) Educate about PTSD & talk to spouse. Educate about PTSD & talk to spouse. Analogy of physical therapy: “frozen shoulder” Analogy of physical therapy: “frozen shoulder”

17 The “A” Problems in PTSD Anger Anger Alcohol Alcohol Avoidance Avoidance

18 Early and Mid-Tx Tasks Therapeutic deed, not just word Therapeutic deed, not just word Assessing and creating coping skills FIRST: distraction, relaxation, music, hobbies, social support, exercise Assessing and creating coping skills FIRST: distraction, relaxation, music, hobbies, social support, exercise Then, constructing the trauma narrative Then, constructing the trauma narrative Hearing the hard stuff and staying present Hearing the hard stuff and staying present Dealing with current life stressors/issues Dealing with current life stressors/issues

19 Middle and Later Therapy Tasks Decreasing affective reactivity: must learn words for emotions (visual to verbal) Decreasing affective reactivity: must learn words for emotions (visual to verbal) Decreasing maladaptive behaviors Decreasing maladaptive behaviors Decreasing “stinking thinking:” with vets, all-or-nothing thinking and paranoia very common Decreasing “stinking thinking:” with vets, all-or-nothing thinking and paranoia very common Increasing some integration into society Increasing some integration into society Increasing self-efficacy: homework Increasing self-efficacy: homework

20 PTSD is a chronic condition Balance instillation of hope with realistic view: there will be exacerbations Balance instillation of hope with realistic view: there will be exacerbations Current stress, medical problems, travel away from home, media exposure to ongoing war, substance use/abuse Current stress, medical problems, travel away from home, media exposure to ongoing war, substance use/abuse Anniversary reactions Anniversary reactions The body remembers The body remembers

21 Potential Pitfalls Secondary traumatization Secondary traumatization Patient dropping out in middle of trauma narrative Patient dropping out in middle of trauma narrative Unrealistic expectations Unrealistic expectations Acting out (patient, not therapist) Acting out (patient, not therapist) Exhaustion (therapist and patient) Exhaustion (therapist and patient)

22 Psychologist Self-Care Balance case-load Balance case-load Peer supervision and/or occasional therapy to “offload baggage” Peer supervision and/or occasional therapy to “offload baggage” Stable and balanced life away from work Stable and balanced life away from work Seeing work as meaningful Seeing work as meaningful

23 Does Therapy Work? 40 years of data on therapy: patient’s rating of the alliance is the best predictor of engagement and outcome 40 years of data on therapy: patient’s rating of the alliance is the best predictor of engagement and outcome All therapy models show that the most change occurs early in the therapeutic process All therapy models show that the most change occurs early in the therapeutic process Therapy accounts for 13% of variance for change (Wampold, 2001, cited by Miller, 2007) Therapy accounts for 13% of variance for change (Wampold, 2001, cited by Miller, 2007)

24 PTSD Therapy Outcome Data Limited data, focuses on: Limited data, focuses on: Exposure-based therapies Exposure-based therapies Cognitive Behavioral Therapy Cognitive Behavioral Therapy EMDR EMDR Small-scale studies, different populations (rape and accident victims, vets), modest treatment gains/effect sizes Small-scale studies, different populations (rape and accident victims, vets), modest treatment gains/effect sizes

25 Difficult to Measure Prevented Behaviors Who did not commit suicide? Who did not commit suicide? Who did not commit homicide? Who did not commit homicide? Who did not drink/use drugs? Who did not drink/use drugs? Who did not abuse family members? Who did not abuse family members?

26 “Maybe the ultimate wound is the one that makes you miss the war you got it in.” “Maybe the ultimate wound is the one that makes you miss the war you got it in.” - Sebastian Junger, “War”


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