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Mindfulness & Acceptance-Based Group Mindfulness & Acceptance-Based Group Treatment for Uniformed Services Treatment for Uniformed Services

Professionals with Complex Trauma: Rationale, Professionals with Complex Trauma: Rationale, Program Description, & Preliminary EvaluationProgram Description, & Preliminary Evaluation

James S. Bastien, LICSW, MHDJames S. Bastien, LICSW, MHDDirector, Uniformed Services ProgramDirector, Uniformed Services ProgramBrattleboro Retreat, Brattleboro, VTBrattleboro Retreat, Brattleboro, VT

Barbara A. Hermann, PhDBarbara A. Hermann, PhDAssociate Director of Research and EducationAssociate Director of Research and Education

National Center for PTSDNational Center for PTSDVeterans Administration, White River Junction, Veterans Administration, White River Junction,

VTVT

Dana C. Moore, MAR, MADana C. Moore, MAR, MAProgram ClinicianProgram Clinician

Brattleboro Retreat, Brattleboro, VTBrattleboro Retreat, Brattleboro, VT

88thth Annual World Conference of the Annual World Conference of the Association for Contextual Association for Contextual

Behavioral Science June, 2010Behavioral Science June, 2010

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Program Rationale There is an estimated 1 million plus uniformed services workers who

witness critical incidents throughout their careers (National Institute of Justice, 1999).

Emergency service workers are at risk for developing PTSD & other psychiatric symptoms (depression) as unanticipated side effects of their employment (Clohessy & Ehlers, 1999).

Professionals who witness trauma may experience a disruption in major beliefs regarding personal safety, vulnerability, benevolence of the world & feelings of powerlessness (Palm, Polusny, & Follette, 2004).

The very characteristics that are valued & reinforced by the professional culture act to dissuade them from seeking help (Wester & Lyubelsky, 2005).

Uniformed service workers are more likely to die from suicide than from work related injuries (Hackett & Violanti, 2003).

PTSD is an inherent “occupational hazard” experienced by a significant number of uniformed service workers (Brough, 2004).

Given the characteristics associated with uniformed services culture, treatment of PTSD for this population presents its own unique set of challenges (Fay, 2006).

Uniformed Service Program

Partial Hospitalization & Therapeutic Community Residence program.

Designed specifically for uniformed professionals; i.e., veterans, firefighters, police, correctional officers, emergency medical personnel (EMTs), dispatchers, critical care nurses.

Group treatment model based on “Third Wave” clinical technologies; ACT, MBSR, & DBT.

Clinical focus on trauma & addiction.

Rolling admissions.

Funded via private insurance, Medicare, & Tri-care.

Co-ed program.

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Clinical Program Components Acceptance & Commitment Therapy

Mindfulness Based Stress Reduction Training

Dialectical Behavior Therapy Skills Groups Culture specific psycho-education classes. Substance abuse psycho-education classes. Trauma informed yoga. Daily aerobic exercise. Peer “Council” practice. AA Meetings

STAY WITH ITSTAY WITH ITWillingness to Experience Willingness to Experience

Emotions vs. Trying to Escape & Emotions vs. Trying to Escape & Avoid ThemAvoid Them

BE HERE NOWBE HERE NOWStaying Grounded in Present Moment Awareness vs. Staying Grounded in Present Moment Awareness vs.

Constantly Living in Your HeadConstantly Living in Your Head

LET IT GOLET IT GOSeeing Thoughts as Just Seeing Thoughts as Just

Thoughts vs. “The Truth” of My Thoughts vs. “The Truth” of My ExperiencesExperiences

JUST DO ITJUST DO ITTaking Committed Action to Taking Committed Action to

Move in Valued Directions vs. Move in Valued Directions vs. Repetition of Unworkable Patterns Repetition of Unworkable Patterns

of Behavior of Behavior

CHOOSE A PATHCHOOSE A PATHChoosing a Direction for Your Choosing a Direction for Your Life vs. Aimless MeanderingLife vs. Aimless Meandering

JUST NOTICE ITJUST NOTICE ITBuying Into & Living Out of Your Self Story vs. Detached Buying Into & Living Out of Your Self Story vs. Detached

Observation of Your Internal & External ExperiencesObservation of Your Internal & External Experiences

Psychological Psychological FlexibilityFlexibility

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Uniformed Services Daily Program Uniformed Services Daily Program ScheduleSchedule

Uniformed Services Daily Program Uniformed Services Daily Program ScheduleSchedule

Sun Mon Tues Weds Thur Fri Sat

Value: Spirituality Health Educ/Self-Dev Rec/Leisure Work Family/ParentPersonal

Rel/Friend

6:30am Wake-Up Wake-Up Wake-Up Wake-Up Wake-Up Wake-Up Wake-Up

7:30am Wellness Wellness Wellness Wellness Wellness Wellness Wellness

8:30am Breakfast Breakfast Breakfast Breakfast Breakfast Breakfast Breakfast

9:00amMBSR

- WalkingMBSR

- Urge SurfMBSR

- Emot/SndsMBSR- Walk

MBSR- Urge Surf

MBSR- Emot/Snds

MBSR- Breath/Snds

9:30am Peer Council Peer Council Peer Council Peer Council Peer Council Peer Council Peer Council

10:30am Break Break Break Break Break Break Break

10:45amSpirituality

GroupACT ACT ACT ACT ACT ACT

11:45pm Lunch Lunch Lunch Lunch Lunch Lunch Lunch

1:00pm ACT PSYED PSYED PSYED PSYED PSYEDPeer

Support

2:00pm Break Break BreakTAP

Break Break Break

2:30pm DBT DBT DBT DBT DBT DBT

3:30pm MBSR-Yoga MBSR-Yoga MBSR-Yoga MBSR-Yoga MBSR-Yoga MBSR-Yoga MBSR-Yoga

4:45pm Dinner Dinner Dinner Dinner Dinner Dinner Dinner

6:00pm Peer Council SA Class Peer Council SA Class Peer Council SA Class Peer Council

7:00pm AA Mtg Peer Council AA Mtg Peer Council AA Mtg Peer Council AA Mtg

8:00pm MBSR MBSR MBSR MBSR MBSR MBSR MBSR

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Resident Demographics Resident Demographics ((nn=18)=18)

Veteran

PoliceFirefigh

terEMT

Corrections Officer

Probation Officer

Other

Uniformed

Service57% 21% 33% 3% 6% 6% 6%

Uniformed Service Type

Post-traumatic

Stress Disorder

Major Depressive

Disorder

Depression NOS

Alcohol Depende

nce

Opioid Depende

nce

Primary Diagnosi

s56% 18% 11% 11% 4%

Primary Diagnosis

Home StateConnectic

utMassachuse

ttsNew York

New Hampshire

Vermont

Home State 11% 43% 4% 14% 25%

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Program Evaluation (N = 34) Pre- to post-treatment changes in outcome and

process measures (t-tests and effect size calculation)

Process-to-outcome associations (correlational analyses)

Outcome Measures:– PCL-C (PTSD Scale-Civilian Version)– PHQ-9 (Patient Health Questionnaire-9 Item Version)

Process Measures:– AAQ-2 (Acceptance & Action Questionnaire-2)– FFMQ (The Five Facet Mindfulness Questionnaire)– CFQ-28 (Cognitive Fusion Questionnaire-28)– VLQ (Valued Living Questionnaire)

Descriptive analysis of Social Validity Measures:– POC (Perceptions of Care Questionnaire).

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Changes in Outcomes

PREM (SD)

POSTM (SD)

M Diff%

Changet(df) d

PTSD(PCL-C) 49.94

(15.88)32.63 (14.25)

-17.31 -34.66 8.60(31)* -1.09

Depression(PHQ-9) 13.73

(7.52)4.82 (5.58)

-8.91 -64.89 7.23(32)* -1.18

* p < .004, with Bonferroni correction

Age (n = 31): M = 46.00, SD = 12.27

Length of stay (n = 34): M = 11.12, SD = 2.73

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Changes in Process VariablesChanges in Process VariablesPRE

M (SD)POST

M (SD)M

Diff

%Chang

et(df) d

Psych Flexibility (AAQ-2)

38.09 (13.53)

51.45 (12.68)

13.36 35.07-

6.90(32)*

0.99

Cognitive Fusion (CFQ-28)

115.55 (35.98)

86.00 (32.49)

-29.55

-25.57

5.23(32)*

-0.82

* p < .004 with Bonferroni correction

Mindfulness (FFMQ)118.39 (26.67)

141.88(29.83)

23.49 19.84-

4.34(32)*

0.88

FFMQ-Observe24.88 (7.32)

28.88 (6.72) 4.00 16.08-

3.07(32)*

0.55

FFMQ-Describe25.06 (8.24)

29.73 (8.10) 4.67 18.64-

3.52(32)*

0.57

FFMQ-Act22.88 (7.57)

28.91 (6.58) 6.03 26.35-

4.46(32)*

0.80

FFMQ-NonJudge25.48 (8.50)

29.76 (7.90) 4.28 16.80 -2.89(32) 0.50

FFMQ-NonReact20.09 (6.66)

24.61 (6.27) 4.52 22.50-

3.91(32)*

0.68

Valued Living (VLQ-I)72.15

(14.86)79.52

(15.92)7.37 10.21

-3.30(32)

*0.50

Valued Living (VLQ-C)50.45

(23.63)75.82

(18.98)25.37 50.29

-4.45(32)

*1.07

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Process AnalysesProcess AnalysesProcess AnalysesProcess Analyses• Two multiple regression analyses were conducted to evaluate how well

the post-treatment process measures predicted PCL-C and PHQ-9 scores.

• At post-treatment, the linear combination of process measures was significantly related to:

• posttraumatic stress, F(10, 21) = 7.16, p = .000,

• depression, F(10, 21) = 4.10, p = .001.

• The sample multiple correlation coefficient for posttraumatic stress symptoms was .89 (79% of the variance).

• The sample multiple correlation coefficient for depression symptoms was .81 (66% of the variance).

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Process Analyses (cont’d)Process Analyses (cont’d)Table 2. Bivariate and Partial Correlations of the Main Process Measures and Outcomes at Post-Treatment (PCL-C: n = 32, PHQ-9: n = 33)

PCL-C PHQ-9

r Partial r r Partial r

AAQ-2 -.85* -.54^ -.76* -.57^

CFQ-28 .77* -.01 .61* -.19

FFMQ -.76* -.11 -.63* -.02

VLQ.I -.47 -.04 -.45 -.14

VLQ.C -.42 -.07 -.37 -.03

*p < .005 for r, ^p < .008 for partial r, with Bonferroni correction

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Perceptions of CarePerceptions of CareDIMENSION OF RESIDENT

CARENever

Sometimes

Usually

Always

1. Staff Explained Things Clearly

0% 0% 22.6% 77.4%

2. Involved in Treatment Decisions

0% 0% 12.9% 87.1%

3. Staff Listened to You 0% 0% 9.7% 90.3%

4. Staff Worked Well as a Team

3.7% 0% 9.7% 87.1%

5. Staff Spent Enough Time with You

2.9% 2.9% 9.7% 83.9%

6. Treated with Respect and Dignity

0% 0% 9.7% 93.5%

7. Staff Gave Reassurance & Support

0% 0% 10.0% 90.0%n n = 31= 31

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Perceptions of CarePerceptions of CareDIMENSION OF RESIDENT CARE

Unsure

No Yes

8. Staff Clearly Explained Program Rules

0% 3.2%96.83

%

9. Staff Gave Information about Patient Rights

0% 3.2% 96.8%

10. Develop & Review an Aftercare Plan with You

0% 3.3% 96.7%

11. Told Whom to Contact in Post Discharge Crisis

6.7% 6.7% 86.7%

12. Told of Aftercare Self Help or Support Groups

0% 3.3% 96.7%

13. Gave Information to Reduce Chance of Relapse

0% 3.3% 96.7%

14. Would You Recommend the Program to Others

0% 0% 100%Dimension of Patient

CareNot At All Somewhat

Quite A Bit

A Great Deal

How Much Were You Helped by the Care You Received? (n = 30)

0% 0% 16.7% 83.3%

Items 8 & 9, Items 8 & 9, n n = 31; Items 10-14, = 31; Items 10-14, n n = 30= 30

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Perceptions of CarePerceptions of CareQualitative Rating Scale

1 2 3 4 5 6 7 8 9 10AVG Ratin

g

On a 1 to 10 scale, what is your overall rating of care? (n = 29)

0%0%

0%

0%

0% 0% 0%13.8%

20.7%

65.5%

9.52

Top notch! Outstanding support, compassion, knowledge!

This program is ‘hands down’ the best care I have ever received! I have a complete new outlook on life.

Was very needed for me and the program was very focused on issues that I was dealing with THANK YOU!

Way beyond my expectations. Thank you all very much! I’m grateful + ‘mindful’ for what took place with the team!

Best program I have ever had, there is no question they have changed my life for the good thank you!

This program is outstanding, If I can ever be of assistance promoting it, please call on me.

This program offered a wonderful education about my issues and a great number of tools for me to continue to live a balanced, healthy and happy life moving forward from here.

I feel again. Thanks to this program.

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DiscussionDiscussion• These preliminary data indicate that the treatment program produced

changes in outcome and process measures as predicted.

• The process measures explained a significant portion of the variance inthe post treatment outcome measures.

• On the basis of the correlational analysis, it may be tempting to conclude that the only possible mediator of change in post-treatment PTSD & Depression symptoms is experiential avoidance as measured by the AAQ-2.

• However, judgments about the relative importance of experiential avoidance as a predictor are difficult due to the high correlations between AAQ-2, CFQ-28, & FFMQ.

• Its possible that experiential avoidance may effectively encompass the other constructs or more efficiently account for the processes hypothesized to drive the present intervention.

• The lack of a unique contribution of the VLQ was an unexpected outcome.

• The program’s participants are reporting high levels of satisfaction with the treatment they received.

Limitations/Future Directions Need to collect formal follow-up data.

Treatment effectiveness may not hold up as clinical group sizes increase with increased census.

Majority of patients were male (92%).

Need to collect treatment integrity measures.

Absence of session-by-session assessment.

Correlation is not a “true” test of mediation as we did not establish that process measures changed before outcomes. Need repeated measures of process variables during treatment.

Limited description of sample characteristics due to program evaluation nature of investigation.