1. John Straznickas, MD VA Medical Center, San Francisco Department of Psychiatry, UCSF

2. Cross-Cultural “Military” Sensitivity Special Issues with PTSD

3. Military Culture Take-Home Points Make an effort to ask and learn about what the military was like for your patient. Know some basic language Don’t hesitate to have them teach you Identify what is your patient’s view of his/her military or veteran experience Examine your own biases Assess for weapons

4. Basic Military History Which Branch did they serve in? They are NOT the same! Peace-time or war-time service? Active Duty, National Guard or Reserves? What was their job/MOS? Involved with combat? Fire-fights, “being shot at”, mortars. Cooks and truck-drivers saw combat Unwanted sexual advances? A major risk factor for military women

5. Individual differences Cultural differences – Vietnam vs. OEF/OIF

6. Viewing the Military as a Culture Cultural values Honor Respect Leave no brother behind Protect yourself - weapons Chain of command Follow orders

7. Veteran as a ‘Racial’ Identity Helms’ Racial Identity Model Conformity Dissonance Immersion/Resistance Internalization Integrative Awareness Slide courtesy of Sam Wan, Ph.D. VA Medical Center, SF

8. Challenging Ways that Veterans Can Present to Community-Based Programs Conformity – Devalues the military and emphasizes the civilian life Dissonance – Ambivalent about the two ‘cultures’ Immersion/Resistance – Idealization of the military and denigration of the civilian culture

9. Using this Model to Facilitate Treatment Engagement The ‘conforming’ veteran Don’t challenge the devaluing…but, Don’t actively join the devaluing The ‘dissonant’ veteran Use Motivational Interviewing techniques to explore the ‘yes-but’ communications The ‘immersion/resistance’ veteran Don’t challenge the devaluing…and, Focus on the present problem and solution

10. Examine Your Own Biases Your view of war Your view of the soldier Your view of perpetrators of violence Your view of perpetrators of atrocities

11. Weapons Assessment Assume that the veteran has one or more weapons Assume that their weapons are an important part of their identity Ask specific questions about how they store the weapon/s and the bullets If suicidality or danger to others is present, negotiate storing weapons (or just bullets) with a friend and/or getting a trigger lock.

12. Substance Use Disorders (SUD) Post Traumatic Stress Disorder (PTSD)

13. Take Home Points for SUD/PTSD 3 C’s: Complex, Confusing and Crisis-prone Don’t blame them or yourself Expect an erratic therapeutic alliance May take multiple treatment contacts Expect more crisis management, more relapses and the need for repeated intensification of treatment structure Have a good relationship with clinical staff at substance abuse day hospitals and substance abuse and/or psychiatric inpatient units

14. Reduces distress Discouragement with poor outcomes

15. More Difficult to Treat … PLUS Worse Outcomes with SUD/PTSD pts Fewer clinical improvements, more crises Uneasy alliance, negative counter- transferences Poorer compliance with aftercare treatments Shorter time to relapse post-treatment Drink more on drinking days More medical and interpersonal problems More homelessness Druley and Pashko 1988, Nace 1988, Brown and Wolfe 1994, Saladin et. al. 1995, Breslau et. al. 1997, Ouimette et. al. 1999, Najavits 1998

16. A double dose of distress

17. Similar Neurobiologic Abnormalities in SUD & PTSD Deficits in titrating level of arousal Disease exacerbation with stress SUD relapse PTSD increase in intrusions and arousal sx Cue-induced behavioral symptoms Over-values and generalizes dangers of PTSD triggers Under-values and fails to generalize dangers of SUD cues

18. Common Therapist Barriers in Forming an Alliance with SUD/PTSD Patients Therapist’s resonance and sympathy with the patient’s state of heightened anxiety and distress leads to fearful treatment thoughts: Fear of SUD relapse if PTSD is addressed Fear of losing the alliance for PTSD work if SUD is addressed. Tuned-out style of patient’s interactions Difficult for therapist to engage in alliance

19. Therapist Suggestions for Working with SUD/PTSD Patients Non-confrontational & Respectful style ‘Parental stance,’ extensive processing of Counter-transference Strongly expressed empathy Flexible approach allowing patients to process multiple traumatic events at a slower, ‘stop & go’ pace Knowledge of PTSD and SUD treatment approaches An explicit, extensive written set of safety parameters for Impulsive behaviors, and Relapse-prevention during PTSD treatment Know methods to overcome non-functional resistance to exposure work. Back et.al (2001) and Najavitis et.al (2008)

20. Common Therapist Barriers in Forming an Alliance with SUD/PTSD Patients Dichotomous Thinking in Therapist Sympathetic victim schema: PTSD is a disorder from an accident Unsympathetic/Repulsive schema: SUD is a disorder of (bad) choices Dichotomous / Non-Integrated Training of Clinicians SUD and PTSD seem to exist in different universes “I don’t know nothin’ about birthin’ no babies PTSD interventions.” No empirical support for an integrated training model (Brady et al., 2001). Clinical treatment programs operate under separate funding for general psychiatry and substance use disorders.

21. Reluctance by PTSD Patients and Therapists to Initiate SUD Treatment Psychosocial and public nature of SUD work. Confrontation of addictive behaviors by some treatment programs Increases arousal (and hostility) 12 Step Challenges to a Military Mind Loss of Control: AA’s core tenet that life has become unmanageable from Alcohol and that they have ‘lost control’ Surrender: Concept of a ‘Higher Power’ and ‘Surrender’ Forgiveness: Fearless moral inventory and making amends Anonymous Group: AA’s crowd of strangers and the telling of ‘war’ stories

22. Evidence for Benefit of PTSD Treatment for SUD Patients Following Inpatient SUD treatment, the amount of PTSD outpatient treatment (3 months or longer) was a major predictor of sustained SUD remission. Ouimette, Moos, Finney 2000 Following Inpatient SUD treatment, partial hospital PTSD Combat trauma processing group showed sustained improvement in PTSD and SUD measures. Donovan 2001

23. Psychopharmacology for SUD/PTSD PTSD Evidence-based medication treatments Sertraline Paroxetine Fluoxetine PTSD Medication trials with ‘few data’: Prazosin Citalopram Fluvoxamine Escitalopram Davidson 2005

24. Psychopharmacology for SUD/PTSD PTSD Medications with ‘some data’: Venlafaxine Mirtazapine Risperidone Ineffective PTSD Medication: Bupropion Davidson 2005

25. General Rules for Med Trials For PTSD patients: Go low and slow to minimize anxiety side-effects For SSRIs 2-12 weeks for 50% reduction in symptoms Improvement continues up to 6 months for a 70% reduction Davidson 2005 For SUD/PTSD patients: Same as above Sometimes for agitation & sleep – go Fast and Heavy Topamax ? Less use of Quetiapine