9-24-13 combat trauma webinar v2...sep 24, 2013 · 9/23/13 6 noonetypeofdualdiagnosis...

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Combat Trauma and Addiction

Presented by: Larry Ashley, Ed.S., LCADC, CPGC, LPC, LMSW

September 24, 2013

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How veterans are affected by hos;le war zones

How combat trauma is different from other trauma;c experiences and how

addic;ve behaviors result

Methods of interven;ons and treatment methods to treat combat trauma and

addic;ve behaviors

Webinar Objectives

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Presented By

Larry Ashley, Ed.S., LCADC, CPGC, LPC, LMSW

Emeritus Associate Professor in Residence at the University of Nevada, Las Vegas and

Clinical Adjunct Faculty in the Physician Assistant Program at Central Michigan University

Are you a veteran?

Audience Polling Question #1

Are you a combat veteran?


Section One

Hostile War Zone Effects

“War is Hell” Poem

War is Hell But That is Not The Half of it.

Because War is Also Mystery and Terror and Adventure and Courage and Discovery and Holiness and Pity and

Despair and Longing and Love. War is Nasty. War is Fun.

War is Thrilling. War is Drudgery.

War Makes You a Man. War Makes You Dead.

-‐ Tim O’Brien

“The Death of a Soul” Poem Did You Know That I Died In Vietnam?

It was not a bloody death. Only the death of my soul. It was the ‘essence of life’ that gave me wholeness.

The link with God and the universe. The inner substance that provides security.

Especially in those desperate hours. It was the Spiritual self that died.

K.I.A 1968! There was no blood, no tangible evidence, no medal,

no letter home announcing the deceased. No prayers and no tears were shed.

Nor has any wall been erected; nor a memorial built. Nothing!

Only a sense of violation. An emptiness, a change, an inner void. An ever-‐present sense of loss.

The kind of loss you feel when you lose a loved one. A heartache that lingers forever with you.

You are left struggling without your spirituality or wholeness. Only an agony remains!

-‐ Darwin D. Savage – 101st. Airborne

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Soldiers And Trauma

  Soldiers learn to tune out feelings in order to survive.

  Some PTSD symptoms, i.e. Hyperarousal and numbing are important survival tools.

  Programmed to kill without feelings.

  Training and experience aid in becoming an “animal” which is “best” soldier in war.

  Ager war, soldiers are supposed to forget about all of the above.

  When under stress, survival skills can reappear.

  Soldiers learn not to address feelings because of nature of war, i.e. can be dangerous to address feelings associated with war under combat.

  It is rare for a Vietnam veteran to not be associated with death, i.e. witnessing, knowing someone who died, and killing.

Death

  How you view death impacts how you view your life.

  Death can be a friend, life can be the enemy.

  Near death experiences can have a las;ng impact.

  If you feel that you are living on borrowed ;me, you live your life differently.

  Loss or fear of death can cause you to take risks.

  Ways of dying have different meanings, i.e. being shot, disease and natural death.

  If you feel unworthy of life, you may not commit suicide, however, you may take chances that may result in death.

Section Two

Combat Trauma Differences & Considerations

World War I (1914 – 1918)

  Evolution of concept that high pressure from exploding shells caused psychological damage leading to symptoms known as “shell shock.”

  Further evolution leads to concept of “war neurosis.”

  Emphasis placed on predisposing personality factors.

World War II (1941 – 1946)

  Idea of predisposing personality factors carried on. Soon became obvious that intrinsic qualities of combat situation must be critical.

  Concept of “combat exhaustion” or “combat fatigue” evolves.

  Psychiatric evaluations up to 300% from World War I.

Korean War (1950-‐1955)

  On-‐site treatment of psychiatric casualties with expectations of return to duty.

  Psychiatric evaluations drop from WWI high of 23% of evacuations to 6%.

  “Traumatic neurosis” leads to gross stress reaction.

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Vietnam War (1964 – 1975)

  Twelve (12) an thirteen (13) month tours, R&R, hot meals, other in-‐field goodies. Psychiatric evacuations drop to 1.2% of total.

  Early 70’s neuropsychiatric disorders begin to increase. Huge increase by the end of troop involvement in 1973.

  Symptoms compared to those of victims of natural disasters, treatment similar to civilian post trauma.

  Lead to the inclusion of PTSD in DSM III.

Drug Abuse Brief History

  During the Civil War alcohol abuse and opium use were common

  22.4% of veterans from Indiana reported alcohol abuse and 5.2% reported other drug use


  During the Vietnam War

  34% of soldiers admitted to marijuana use and 50% admitted to heroin use


  In 1980, the Military began a no tolerance policy on illegal drug use

  Prevalence declined from 27.6% to 3.4% in 2002

Post Traumatic Stress Disorder Comparisons Between Vietnam and Other Wars

  Sense of Purpose – “Patriotism”

  Homecoming: Peace Marches vs. Victory Parades

  Guerilla Warfare

  Average Age 19 vs. 26

  Body Count vs. Terrain Objective

  12 or 13 Month Tour

  Did Not Depart/Return as Unit

Signs & Symptoms of PTSD & Combat Trauma

  Re-‐experiencing (memories, images, dreams with distress)

  Hyper-‐arousal (e.g. sleep problems, irritability/anger, startle, hyper-‐vigilance)

  Avoidance (thoughts, feelings, activities, people)

  Numbing (e.g., restricted emotions, lack of positive feelings)

  Common Problems

  Sleep problems, nightmares, avoidance of sleep

  Social withdrawal/isolation

  Intense anger over routine issues

  Easily startled

  Depression

  Guilt

  Feeling unsafe in reminder situations

  Substance abuse

  Difficulty with other people (e.g., feeling distant, different)

  Poor self-‐care

  Suicidal thought

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Main Groups of Symptoms

1)  Re-‐living an event   e.g., nightmares and flashbacks related to a combat

situation

2)  Avoiding reminders of the event

  e.g., isolating oneself from veteran peers

3)  Being on guard or hyper-‐aroused   e.g. being on edge or restless due the combat

exposure

Which of these main symptom groups do you most often see

in your clients?


Diagnostic and Statistical Manual Evolution

  DSM I (1952) – Gross Stress Reaction – Characterized by an individual being exposed to extreme emotional and physical stress such as combat.

  DSM II (1968) – Category deleted – Only mention of combat related stress in context of adult adjustment reactions. Implication that there could be more stress or less appropriate adjustments to combat stress.

  DSM III (1980) – PTSD Acute, chronic and/ or Delayed. Acute type of PTSD is synonymous to “shell shock” or “combat fatigue.” Chronic and or delayed subtypes have special relevance to veterans of the war in Vietnam.

  DSM IIIR – Clarified that stressors associated with the onset of PTSD were external events outside the usual range of daily hassles of life that would be “markedly distressing to most everyone.” In addition, clarified the various ways that traumatic events can be re-‐experienced.

  DSM IV – Minor revisions in language for defining the criteria established in DSM IIIR.

  Partner conflict-‐divorce prevention

  Sexual functioning

  Parenting

  Budgeting skills

  Domestic violence

  Impact of PTSD on above

  Impact on family members

Impact of Combat Trauma & PTSD on the Family

Public Health Concerns Associated with PTSD

  Drug and Alcohol Abuse

  Homelessness

  Suicide

  Illness (Physical and Mental)

  Effects on the Family

  Dual diagnosis an expectation, not an exception

  Both diagnosis primary, secondary only if it resolves when co-‐morbidity is at baseline

  Both diseases fit in disease & recovery model

Co-‐Occurring Disorders

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 No one type of Dual Diagnosis program, individualize

 Addiction treatment for mentally ill same for non-‐psych

 Addiction treatment requires modification for patients with psychiatric disorders


  75%of Vietnam veterans who meet the criteria for PTSD also meet the criteria for a substance related disorder

  Many connec;ons between problem gambling and substance abuse

o  Gambling environment can also encourage a substance addic;on (Example: free alcohol to gamblers) Yet, different from other substance addic;ons because there is no natural sa;a;on point

o  Prevalence of pathological gambling in the military is 1.2%

  Depression   Anxiety   Ea*ng disorders


Depression

  Symptoms last for at least two weeks

  Depressed feeling or cannot enjoy life

  Has problems with eating and/or sleeping

  Guilt feelings

  Loss of energy

  Trouble concentrating

  Thoughts of death

Anxiety

  Panic Disorder – repeated panic attacks

  Phobia – specific or social

  Obsessive-‐Compulsive Disorder – repeated thoughts or behaviors that appear senseless

  Posttraumatic Stress Disorder

  Generalized Anxiety Disorder – no panic but feel tense and anxious

  Acute Stress Disorder – Like PTSD but lasts less than a month

  Anorexia Nervosa – inability to maintain minimum body weight (binge eating/purging or restricting)

  Bulemia – binge eating with inappropriate ways of controlling weight (laxatives, self-‐induced vomiting)

  Patients with eating disorders have the highest suicide risk of all psychiatric disorders

Eating Disorders

Diagnosis Adults

ANY PSYCHIATRIC COMORBIDITY 97%

ANY DEPRESSIVE DISORDER 90%

Major Depression 56%

Dysthymia 12%

Depression Not Otherwise Specified 36%

Bipolar Disorder 5%

Attention Deficit/Hyperactivity Disorder 7%

ANY ANXIETY DISORDER 65%

Obsessive-‐Compulsive Disorder 19%

Generalized Anxiety Disorder 20%

Social Phobia 5%

Anxiety Not Otherwise Specified 27%

Post-‐Traumatic Stress Disorder 24%

Co-‐occurring Psychiatric Diagnoses of Patients with Eating Disorders

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  Many turn to alcohol and drug abuse in an attempt to cope with memories and other psychological and physical symptoms

  It has been reported that of the 42.2% of participants with alcohol dependence, 33.3% of those also had other psychiatric disorders, such as depression, mood disorders, or PTSD

  It is estimated that 35-‐75% of veterans with Posttraumatic Stress Disorder (PTSD) abuse alcohol or other drugs

Self-‐Medication Theory

Pathological Gambling

  Preoccupation

  Increasing bets

  Returns to gambling to get even (chasing)

  Increasing in bets and activity than intended

  Impairment of social and occupational

  Inability to stop in spite of negative consequences

Chemical Dependency

  Preoccupation

  Tolerance

  Withdrawal

  Taken in larger amounts than intended

  Impairment of social and occupational life

  Continued use in spite of negative consequences

Pathological Gambling vs. Chemical Dependency

  19.1% of OIF returnees screened positive for mental health concerns

  11.3% OEF

  Concerns:

o  PTSD

o  Suicidal ideation

o  Interpersonal conflicts

o  Interpersonal aggressive ideation

Problems Post-‐Deployment

What percentage of Veterans experience co-‐occurring disorders?


  25% received mental health diagnoses

  56% of these had 2+ diagnoses

  60% of diagnoses first made in non-‐mental health

  e.g., primary care

  Younger veterans (18-‐24) more likely to receive diagnoses of PTSD and other mental health disorders than age 40+

  Seal et al. (2007)

MH Disorders Among Veterans Using VHA Facilities

Potentially Traumatic Deployment Experiences

  Fear, helplessness and horror

  Traumatic loss of comrades

  Perceived moral transgression

  Exposure to mass death/suffering

  Helplessness in the face of suffering

MH Disorders Among Veterans Using VHA Facilities

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Causal Factors

  Cultural Reassignment

  Stress

  Deployments

  Retirement

  Homelessness

  The process in which new members of the military are thrust into a situation in which they must learn a new vernacular, way to dress and everyday rituals.

  After all of the arduous training, new recruits feel a tremendous sense of pride and patriotism.

  They may be introduced to new social norms of alcohol and/or drug use.

  Drinking is often an acculturated norm.

  Potential alcohol and/or drug addictions may have developed in the veterans well before release from duty, and these addictions are thence carried into the civilian world.

Cultural Reassignment

  Deployments, death of service personnel, frequent moves, and retirement from service.

  Self-‐medication may be used to cope with these stressors.

Stress

  Mul;ple stressors related to past military experience and combat in par;cular are most ogen cited by veterans in treatment for substance-‐related disorders

  Members who are deployed for long periods of time lose the sense of security that a consistent family environment establishes.

  Divorce rates, spousal abuse and infidelity are also correlated with deployments.

  Many veterans who had been deployed into combat may not get the help they need to adapt to the civilian world, potentially destroying what family system of support they may have had.

  Loss of a supportive family environment, though not unique to veteran alcohol and/or drug users, can exacerbate current substance abuse problems and delay treatment for this group.

Deployments

Retirement Homelessness   Requires relearning civilian

roles, rules, and obligations

  Those veterans who can successfully make this adjustment are less likely to turn to negative coping strategies compared with those who do not successfully reintegrate.

  The Department of Veterans Affairs reports that 30% of the adult homeless population is believed to be veterans

  Alienation from civilian society, trauma-‐related guilt, and problem maintaining employment have all contributed to the relatively greater social isolation seen in veterans.

  Outpatient

  Intensive Outpatient

  Extreme cases-‐Residential Treatment

  Medical Management

  Currently, few options for treatment of problem gambling

  Motivational Interviewing

  Prochaska & DiClemente Trans-‐theoretical model

  Substance abuse agencies should ALWAYS do a gambling screening (*Many times overlooked)

Treatment Modalities

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  Assessment

  PTSD education

  Support and problem-‐solving

  Medications

  Individual therapy

  Group services

•  Support groups

•  Education groups

  Specialty groups

•  Coping skills training

•  Anger management

•  Stress management

•  Couples groups

•  Trauma focus groups

  Support from other veterans

PTSD Treatment

  In 1999, slightly over 65,000 veterans were admitted into substance abuse treatment. o  68% of admissions were for alcohol, 13% for cocaine, 8% for

opiates, 6% for marijuana, 2% for stimulants, and 3% for other drugs.

  By 2004, nearly 60,000 veterans were admitted into substance abuse treatment. o  61% of admissions were for alcohol, 15% for cocaine, 10% were

for opiates, 7% for marijuana, 4% for stimulants, and 3% for other drugs.

Veteran Alcohol and Drug Treatment Statistics

  Alcohol abuse and dependence stands out as the primary drug of choice among veterans.

  Cocaine-‐related admissions and opiate-‐related admissions have increased over time.

Veteran Alcohol and Drug Treatment Statistics

Section Three

Intervention & Treatment Methods

  The military refers to its counseling clinics as the Life Skills or Mental Health Office.

  Military clinical psychologists and social workers use the Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Program to treat alcohol and drug abuse problems.

Treatment Issues & Considerations

  The identification, treatment, and management, mandatory, frequent, and unpredictable urine testing

  Veterans may not seek treatment due to the continued stigma of receiving treatment.

  Private-‐practice counselors with an interest (and knowledge) of working with this group are greatly needed.

Treatment Issues & Considerations

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  Alcoholics Anonymous, Gamblers Anonymous, etc.

  Social, Family, and Military Support

  Developing stress management skills

  Self-‐discovery, accepting change, maintaining a sense of humor

Spirituality in Trauma Recovery Implications For Treatment For Warrior Therapists

  All therapists who have survived similar trauma to that client’s will be faced with the issue of therapeutic distance and objectivity.

•  Relating can give insight and sensitivity.

•  Can also obscure client’s uniqueness.

  Remember that client is struggling with relinquishing power and accepting vulnerability.

•  Most clients of trauma suffer from alexithymia, have poor vocabulary of emotional identifying words, i.e. hard to express feelings.

•  Therapist may be more active than usual.

  Must be aware of own feelings.

  Must strive for personal integration. As a role model, own comfort with both sides of self, impact client.

  The warrior therapist can make unique contribution in helping warriors become former warriors.

Impact Upon the Warrior Therapist

  Advantages to Therapist

-‐ Potential benefits of participating in a therapeutic relationship.

-‐ The satisfaction of helping comrades.

  Possible Disadvantages

-‐ Exposure to additional traumatic affect.

-‐ The resurrection of emotional numbing and distancing defenses.

-‐ Over-‐identification with the client.

-‐ Exacerbation of survivor guilt.

-‐ Shift from emphasis on therapy to victim advocacy.

Is PTSD a family disease?


Mason/Why is Daddy Like He is?

“When Daddy was in the war some of his friends were killed too. But there was too much danger to sit down and cry. When you cried about the kiPy, it helped you feel BePer, remember?” Mom said. “Daddy had to get a liPle angry to stay alive, and he never got the chance to cry, so he’s stuck in being angry a lot of the ;me. Remember how mad you were at whoever ran over your kiPy? Well, daddy is that mad, too. He’s angry about what happened in the war, But the anger ends up ge]ng splaPered all over us.”

Implications For Employee Assistance and Substance Abuse Professionals

  Most Vietnam veterans are employed.

  All EAP and SAP’s have at sometime worked with Vietnam veterans.

  “Functional PTSD’er’s”

  Vietnam veterans often respond to violence and threats in different ways than the average worker.

  Family members of Vietnam veterans are often seen by EAP’s and SAP’s.

  EAP’s and SAP’s need to become familiar with the frame of reference that combat veterans bring to the treatment setting.

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  Hoge et al. 2004, NEJM

  Hoge et al., 2006, JAMA

  Kennedy, C.H., Zillmer, E.A. (2006). Military Psychology. New York, NY: The Guilford Press.

  Ruzek, J.I. (2007). Meeting the Post-‐Deployment Readjustment Needs of Military Members. Powerpoint Presentation. Las Vegas, NV. 3/23/07.

  Spahr, A.N., Wall, A.D., Wandler, K.R. (2007). Suicidality and Eating Disorders. The Bermuda Review: The Christian Journal of Eating Disorders, Vol 6 Issue 2, p.14-‐24.

References

Thank you for participating!

1001 N. Fairfax Street., Ste. 201 Alexandria, VA 22314 phone: 703.741.7686/800.548.0497 fax: 703.741.7698/800.377.1136 mis;@naadac.org www.naadac.org/educa;on

Larry Ashley, Ed.S., LCADC, CPGC, LPC, LMSW [email protected]

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Obtaining CE Credit

o  The educa;on delivered in this webinar is FREE to all professionals.

o  2 CEs are FREE to NAADAC members who aPend this webinar. Non-‐members of NAADAC receive 2 CEs for $25.

o  If you wish to receive CE credit, you MUST complete and pass the “CE Quiz” that is located at: (look for TITLE of webinar)

  www.naadac.org/educa;on/webinars

o  A CE cer;ficate will be emailed to you within 21 days of submi]ng the quiz and payment (if applicable) – usually sooner.

o  Successfully passing the “CE Quiz” is the ONLY way to receive a CE cer*ficate.

Thank you for participating!

1001 N. Fairfax Street., Ste. 201 Alexandria, VA 22314 phone: 703.741.7686/800.548.0497 fax: 703.741.7698/800.377.1136 mis;@naadac.org www.naadac.org/educa;on

Larry Ashley, Ed.S., LCADC, CPGC, LPC, LMSW [email protected]

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9-24-13 combat trauma webinar v2...sep 24, 2013 · 9/23/13 6 noonetypeofdualdiagnosis...

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