CHALLENGES to TREATMENT of COMBAT PTSD John Mundt, Ph.D. drjohnmundt@hotmail.com

CHALLENGES to TREATMENT ofCOMBAT PTSD

John Mundt, Ph.D.

drjohnmundt@hotmail.com

www.drjohnmundt.com

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 TraumaCommon Therapist Error: failure to assess for

other traumaCan 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

CHALLENGES TO TREATMENT

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

1 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.

TRAUMATIC BRAIN INJURY (TBI)

ADDICTION and SUBSTANCE ABUSE

Alcohol, cocaine and methamphetamine were available in IraqAfghanistan is world’s largest producer of opiumMany 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

CHALLENGES TO TREATMENT

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 hypervigilanceInsomniaDepressionAnger and volatility

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

CHRONIC PAIN

Boredom/ isolation/ avoidance

Culture of drinking

ADDICTION and SUBSTANCE ABUSE

DAY HOSPITAL PROGRAM approach: Detailed assessmentPsychoeducation: - use vs. abuse vs. dependence

-abuse = impairments in functioning (emotional, vocational, social, physical)

Emphasis on honesty over total abstinenceLapses are a part of recovery: lapses are not

relapses, but may lead to themContinued 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

CHALLENGES TO TREATMENT : SUICIDE

Lessons from Vietnam

Literature: Both trauma exposureand specific diagnosis of PTSD are linked with suicidal behavior. Why?

Despair ImpulsivityGuilt / 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 behavioro Calling friends, particularly vets, to say

goodbyeo Cleaning weaponso Visiting graveyardso Stopping or hoarding medication, alcoholo Spending sprees, buying giftso Obsession with media coverage of waro 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 : SUICIDE

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

CHALLENGES TO TREATMENT : VIOLENCE

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

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

CHALLENGES TO TREATMENT

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 non-combat trauma

• Consider possible causes of failure to disclose(subjectively “unsafe”, security clearances, classified “black ops”)

#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 !

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

#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 things to do in Session #1 !

#10: Give something to read

-pamphlets-reading list-websites

drjohnmundt@hotmail.com

www.drjohnmundt.com