SOWK 640 Case Presentation Unit 8

Substance Abuse in the Military Family

presented by: Alma Garcia and Laura O’BrienFebruary 26, 2014

brief discussion of role within the agency: social worker

• substance abuse counselor

• provide resources to the family as a described need by the family members

• provide information unknown to family to help them achieve harmony & autonomy

• psychoeducation; counseling; referrals; case management

Kadis & Walls, D. (2006).

Introduction: meet “Luisa”

•All sessions begin with a full biospychosocialspiritual assessment

•Disclosure forms and consent forms have been signed. Client’s name has been changed for this presentation.

•Luisa is self-referred at her husband’s request

Bio/Psycho/soc/spiritual

• 38 year old female

• married (10 years), husband: Jack (40)

• 2 children: Sam (4) & Isabel (2)

• American born; first generation“Latina”; Catholic

• no forthcoming information on family history with the exception of being close to her father

• High-school graduate; pre-deployment, school bus driver, and at home Mom

bio/psych/soc continued

•no physical or psychological problems before deployment

•hobbies: reading, writing, hiking, running volunteering at the pre-school, yoga

•attends Catholic church with the family; and as a youth with her family

Military

•Serves in the National Guard Reserves

•Enlisted in 2009

•Deployed 12/2012 to Afghanistan for 12 month tour

presenting issues (observed and disclosed)

• fighting with spouse

• isolation

• lack of sleep

• feeling alienated by family

• hypersensitivity; hypervigilence

• flashbacks and nightmares

• anger

• increase of alcohol and marijuana

• lack of trust; over analyzing

• depressed

assessment tests• Michigan Alcoholism Screening Test (MAST) -- score 19 = high

abuse and dependency

• Drug Abuse Screening Test (DAST) -- score of 10 = high for abuse or dependency for cannabis.

• PCL-17 and scored very high in posttraumatic stress disorder (PTSD).

• Luisa has no suicidal or homicidal ideation, however, this will be continually assessed (Cato, 2013).

• According to the DSM-5, Luisa has posttraumatic stress disorder 309.81 (F43.10) with dissociative symptoms which are not related to substance use (American Psychiatric Association, 2013). Luisa meets all criterions, A-H. Luisa’s descriptions of: “thinking she’s awake when she’s not”; “feels that life is a super-imposed nightmare on real life”; and “ life is like walking under water, all funky, not real” qualify her for the dissociative symptom criteria (Gabriel and Wain, 2007).

• Comorbid diagnoses include alcohol use disorder 303.90 (F10.20) which is considered moderate with the presence of four to five symptoms (American Psychiatric Association, 2013, pp. 490-491) and cannabis use disorder 304.30 (F12.20), considered severe, with a presence of six or more symptoms (American Psychiatric Association, 2013, p. 509-510).

Luisa’s strengths

• hope

• love of family

• love from family

• hope for future

• resiliency

• spirituality

• self-sufficient & independent

challenges

•diversity: female in military; first generation Latina; religion (in respect to facility)

•self-sufficient & independent

•birth control

•reintegration with family

•fear of sexual assault

GOAL of Treatment

• “Increasing the ability to replace impulsive reactions with reflective reality-based decisions is critical to managing both intrusive trauma memories and the cravings for substances and automatic behavior patterns that sustain addiction” (Ford & Russo, 2006, pp. 336 – 337).

treatment plan

Inpatient therapy (remember: she is self-referred. She does NOT Inpatient therapy (remember: she is self-referred. She does NOT

want to involve the VA. Wants to be anonymous. Wants to re-want to involve the VA. Wants to be anonymous. Wants to re-

deploy)deploy)first 30-days of treatment = (lock down) for Luisafirst 30-days of treatment = (lock down) for Luisa

6 month duration total6 month duration totalfamily enter treatment after 30-daysfamily enter treatment after 30-days

MI/PST/CBT for substance abuseMI/PST/CBT for substance abuse(other services: MFT, spiritual, anger management, D&A classes, (other services: MFT, spiritual, anger management, D&A classes,

grief and loss classes, relapse prevention, 1:1 weekly grief and loss classes, relapse prevention, 1:1 weekly counseling, AA/NA)counseling, AA/NA)

reconnection with familyreconnection with familybe better mother/wifebe better mother/wifehelp her lack of sleephelp her lack of sleep

normalization of her lifenormalization of her lifereduce angerreduce anger

Trauma Focused CBT for PTSD & Substance Abuse

• The goal of psychotherapy is for the PTSD & SA interventions to compliment each other.

• Hyperarousal can lead to self-medication to relieve anxiety.

• Hypervigilance can lead to drug use that increases the ability to remain alert.

• The goal is for the intervention to work on affect regulation skills and improve or develop social problem solving skills.

TTrauma Focused Cognitive Behavioral Therapy basis is Cognitive Behavioral

Theory

• A Cognitive Behavioral Therapy (CBT) approach emphasizes correcting maladaptive cognitive distortions that have been acquired. These maladaptive thoughts are restructured in order to reduce intrusive symptoms of emotional numbing, hyperarousal, hypervigilance, and re-experiencing.

• CBT focuses on helping identify trauma-related triggers and manage the reactions. The goal is to replace the maladaptive coping skills, in this case substance abuse, with adaptive one.

Challenges of CBT

• Much of the research on CBT for clients with PTSD has not included those with comorbid substance abuse disorders.

• Clients with both disorders have a more severe profile than those with just one disorder as it affects course & outcome.

• These patients have a higher chance of meeting criteria for additional disorders such as anxiety and major depression disorders.

various models researched• EMDR--Eye movement desensitization and reprocessing is nontraditional type of

psychotherapy for treating post-traumatic stress disorder. PTSD often occurs after experiences such as military combat, physical assault, rape, or car accidents. The Department of Veterans Affairs and the Department of Defense have jointly issued clinical practice guidelines. These guidelines "strongly recommended" EDMR for the treatment of PTSD in both military and non-military populations. (Department of Veterans Affairs, 2013)

• Prolonged exposure used such as a 16 – week intervention combining with cognitive restructuring.

• Seeking Safety agency for specific care that integrates treatment for PTSD and substance abuse (Najavits, 2002; 2007; and 2009). Many of the same educational areas such as relationships, setting boundaries, and substance abuse overlap but, the focus on attending sessions will carry into other areas concerning military life and specific concerns not addressed at the ARC. The ARC’s primary concern is substance abuse, so Seeking Safety will provide necessary treatment focused on the comorbidity of SUD and PTSD (Bowden, Bowmen, Carney, Jacob-Lentz, Kimerling, Trafton, Walser, & Weaver, 2011).

• A 12 week partial hospital group CBT intervention that included 6 & 12 month follow-ups.

• An Assisted Recovery Trauma & Substances model include a 20 week intervention. The first 11 sessions of CBT focused on substance abstinence were one-on-one therapy. Then 29 sessions of individualized and paced CBT for PTSD.

• American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, 5th Ed. Arlington, VA: American Psychiatric Association

• Barlow, D., and McHugh, R. (2010). The dissemination and implementation of evidence-based psychotherapy treatments: Review of current efforts. American Psychologist, 65(2), 73-8

• Bowden, M., Bowmen, D., Carney, D., Jacob-Lentz, J., Kimerling, R., Trafton, J., Walser, R., Weaver, C. (2011). Seeking safety treatment for male veternans with a substance use disorder and post-traumatic stress disorder symptomatology. Addiction. doi: 10.1111/j.1360-0443.2011.03658.x. Retrieved from: http://www.seekingsafety.org/7-11-03%20arts/2012%20boden%20ss%20study.pdf

• Briere, J., and Scott, C. (2012). Assessing trauma and posttraumatic outcomes. In Principles of trauma therapy: A guide to symptoms, evaluation and treatment, 2nd Edition (chap. 3, pp. 49-78). Thousand Oaks, CA: The Guilford Press.

• Bryant, R. (2011). Post-traumatic stress disorder vs traumatic brain injury. Dialogues in Clinical Neuroscience. Vol. 13(3): 251-262. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3182010/

• Cato, C. (2013). Suicide in the Military. In Rubin, A., Weiss, E. & Coll, J. (Eds.). Handbook of Military Social Work (pp. 225-244), Hoboken, New Jersey: John Wiley & Sons, IncColl, J., Metal, M., and Weiss, E. (2013). Military culture and diversity. In Rubin, A., Weiss, E. & Coll, J. (Eds.). Handbook of Military Social Work (pp. 21-36), Hoboken, New Jersey: John Wiley & Sons.

• Department of Veterans Affairs. (2004). Veteran's Health Initiative: Traumatic brain injury―Independent study course. Washington, DC: Department of Veterans Affairs

• Ford, J. D., & Russo, E. (2006). Trauma-focused, present-centered, emotional self-regulation approach to integrated treatment for posttraumatic stress and addiction: trauma adaptive recovery group education and therapy (TARGET). American Journal of Psychotherapy, 60(4).

References

References continued

• Gabriel, G. and Wain, H. (2007). Psychodynamic concepts inherent in a biopsychosocial model of care of traumatic injuries. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 35(4), 555-573.

• Greenberger, D., and Padesky, C. (1995). Mind over mood. New York: Guilford Press.

• Kadis, J., and Walls, D. (2006). Military facts for non-military social workers. Washington, DC: Veterans Health Association Handbook.

• Leach, S and Nidiffer, F. (2010). To hell and back: Evolution of combat-related post-traumatic stress disorder. Developments in Mental Health Law, Vol. 29(1), 1-22.

• Martin, J. (2000). Afterword: The changing nature of military service and military family life. In J. A. Martin, L. N. Rosen, & L. R. Sparacino (Eds.), The military family: A practice guide for human service providers (pp. 257-270). Westport, CT: Praeger.

• Najavits, L (2002). Seeking Safety: A treatment manual for PTSD and substance abuse. NY: Guilford Press

• Najavits, L. (2007).  Seeking Safety: An evidence-based model for substance abuse and trauma/PTSD.  In: KA Witkiewitz & GA Marlatt (Eds.), Therapists' Guide to Evidence-Based Relapse Prevention: Practical Resources for the Mental Health Professional, pages 141-167.  San Diego: Elsevier Press

• Najavits, L. (2009). Seeking Safety: An implementation guide. In A. Rubin & DW Springer (Eds). The Clinician's Guide to Evidence-Based Practice. Hoboken, NJ: John Wiley.

• Pardini, D., Plante, T., Sherman, A, and Stump, J. (2000). Religious faith and spirituality in substance abuse recovery: Determining the mental health benefits. National Library of Medicine. Vol. 19 (4): 347-54. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/ 11166499

• Safer, M., and Van Winkle, E. (2011). Killing versus witnessing in combat trauma and reports of PTSD symptoms and domestic violence. Journal of Traumatic Stress, 24(1). 107-110.

• Schäfer, I., & Najavits, L. M. (2007). Clinical challenges in the treatment of patients with posttraumatic stress disorder and substance abuse. Current Opinion in Psychiatry, 20(6), 614-618.

• Schnurr, P. P., Friedman, M. J., Engel, C. C., Foa, E. B., Shea, M. T., Chow, B. K., ... & Bernardy, N. (2007). Cognitive behavioral therapy for posttraumatic stress disorder in women: a randomized controlled trial. Jama, 297(8), 820-830.

Thank you.