Challenges in War and At Challenges in War and At HomeHome

Steve Scruggs, Psy.D.Steve Scruggs, Psy.D.OEF/OIF Readjustment ProgramOEF/OIF Readjustment Program

Team LeaderTeam LeaderOklahoma City VA Medical CenterOklahoma City VA Medical Center

Volunteer Clinical Assistant Volunteer Clinical Assistant Professor, OUHSCProfessor, OUHSC

OverviewOverview

Military cultureMilitary culture The making of a WarriorThe making of a Warrior Realities of combatRealities of combat Readjustment problemsReadjustment problems Successful transitionSuccessful transition

What Is Cultural Competency?

Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations.

US Dept of Health and Human Services, Office of Minority Health

Culture/CompetenceCulture/Competence

Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.

Competence implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities. (Adapted from Cross, 1989).

What does military culture What does military culture value?value?

ObedienceObedience DisciplineDiscipline Structure (including hierarchy)Structure (including hierarchy) Toughness (mental and physical)Toughness (mental and physical) Training/Following SOPs (standard operating Training/Following SOPs (standard operating

procedures)procedures) Completing the mission regardless of Completing the mission regardless of

hardshipshardships Up or outUp or out

Why do people join?Why do people join?

IdealisticIdealistic

I want to serve my I want to serve my country.country.

I want to defend I want to defend America.America.

I want to lead people in I want to lead people in battle.battle.

I want to be the best I I want to be the best I can be.can be.

I want to test myself.I want to test myself.

PracticalPractical

I’m not ready for college-I’m not ready for college-don’t know. what I want don’t know. what I want to do.to do.

I want college money.I want college money.

I want to learn a skill.I want to learn a skill.

I was homeless and had I was homeless and had no where to go.no where to go.

I thought it would help I thought it would help me shape up.me shape up.

Enlisted/OfficerEnlisted/Officer

85%85%E-1-3 Worker E-1-3 Worker E-4 JourneymanE-4 JourneymanNon-Commissioned Non-Commissioned Officers (NCO)Officers (NCO)E-5-6 Mid LevelE-5-6 Mid LevelE-7-8 Senior NCOE-7-8 Senior NCOE-9 Top 1%E-9 Top 1%

15%15%O-1-2 PlatoonO-1-2 PlatoonO-3 CompanyO-3 CompanyO-4-5 Mid levelO-4-5 Mid levelO-6+ Senior leaderO-6+ Senior leader

Warrant Officers 1-4Warrant Officers 1-4

Preparation for warPreparation for war

Intention exposure to stress, in a gradual, Intention exposure to stress, in a gradual, planned wayplanned way

High expectations/commitment requiredHigh expectations/commitment required Training to promote “muscle memory”Training to promote “muscle memory” Expectation is “You are going to war"Expectation is “You are going to war" The mission is worth risking your life for…The mission is worth risking your life for…

The Role of AggressionThe Role of Aggression When faced with a threat (fight/flight)When faced with a threat (fight/flight)

FIGHT!FIGHT! Starts the first day of basic trainingStarts the first day of basic training Used by role models (Drill Instructors, leaders)Used by role models (Drill Instructors, leaders) Used to “motivate” troopsUsed to “motivate” troops Learn to either shut up and do what you are Learn to either shut up and do what you are

told or get in someone’s facetold or get in someone’s face Go immediately to aggression if any “push Go immediately to aggression if any “push

back”back”

The Development of a WarriorThe Development of a Warrior

Basic trainingBasic training Military Occupation Specialty (MOS) Military Occupation Specialty (MOS)

training (AIT, Tech School)training (AIT, Tech School) Assignment to a unitAssignment to a unit Learning the job in the “real” militaryLearning the job in the “real” military Pre-deployment training, with increased Pre-deployment training, with increased

work hours and higher expectationswork hours and higher expectations DeploymentDeployment

Realities of CombatRealities of Combat Long hoursLong hours Constant vigilance (no battle lines to get behind)Constant vigilance (no battle lines to get behind) The enemy intentionally seeks to disrupt The enemy intentionally seeks to disrupt

(mortars at night, during chow)(mortars at night, during chow) Mission may be unclear (occupying force)Mission may be unclear (occupying force) Ambiguous situations are common (friend or Ambiguous situations are common (friend or

foe?)foe?) Rules of Engagement (ROEs) may change Rules of Engagement (ROEs) may change

arbitrarilyarbitrarily

A Soldier’s PerspectiveA Soldier’s Perspective

Constantly guarded, watchful and alertConstantly guarded, watchful and alert Wired and tiredWired and tired Increasingly gruff, impatientIncreasingly gruff, impatient Strong ties, strong dislikesStrong ties, strong dislikes Worry about home or emotional distancingWorry about home or emotional distancing Emotional numbingEmotional numbing

Do your job no matter what happensDo your job no matter what happens ““Shut up and drive on…”Shut up and drive on…”

Realities of CombatRealities of Combat

When a traumatic event occurs, the When a traumatic event occurs, the mission is still the prioritymission is still the priority

Processing emotions related to traumatic Processing emotions related to traumatic events is often delayed or avoidedevents is often delayed or avoided

Numbing of emotions is adaptive (short Numbing of emotions is adaptive (short term)term)

Distancing from others is adaptive (short Distancing from others is adaptive (short term)term)

A Soldier’s Perspective…A Soldier’s Perspective…

Often, there is a disillusionment of:Often, there is a disillusionment of:

ExperienceExperience

Military organization/LeadershipMilitary organization/Leadership

SelfSelf

Change in OutlookChange in Outlook

Changes are life savingChanges are life saving Changes become “the new normal”Changes become “the new normal” Changes may be celebratedChanges may be celebrated

I need this to be safeI need this to be safe Civilians are unprepared, stupid, naïveCivilians are unprepared, stupid, naïve

Reinforcing information is paid attention to Reinforcing information is paid attention to or even sought out (news of drive by or even sought out (news of drive by shooting, home invasions, robberies, mass shooting, home invasions, robberies, mass shootings, etc.)shootings, etc.)

Return/ReunionReturn/Reunion

Honeymoon phaseHoneymoon phase Disappointment due to problems or unmet Disappointment due to problems or unmet

expectationsexpectations Others expect the soldier to quickly return to Others expect the soldier to quickly return to

“normal”“normal” Frustration buildsFrustration builds Expression of anger is more intense and not Expression of anger is more intense and not

acceptable (like it was in theater of combat)acceptable (like it was in theater of combat)

Common Readjustment IssuesCommon Readjustment Issues

Problems getting Problems getting and staying asleepand staying asleep

Occasional Occasional nightmaresnightmares

Constantly alert Constantly alert and guardedand guarded

Uncomfortable in Uncomfortable in crowded placescrowded places

More gruff, irritableMore gruff, irritable

More goal oriented More goal oriented (have problems (have problems relaxing)relaxing)

Thinking about Thinking about combat combat experiences (even experiences (even when you don’t when you don’t want to)want to)

Why do sleep problems develop after combat and trauma? (Dr Rob Braese)

Unhealthy or erratic sleep patterns Night shift, long missions 

Reinforcement Poor sleep is often rewarded (when you are

alert and sleep light you feel safer) Good, sound sleep is often punished

(attacks at night often make people feel vulnerable)

Why do sleep problems develop after combat and trauma?

New sleep habits More caffeine, drinking to fall asleep

Physical changes following deployment Pain and injuries make it hard to sleep  

Mental changes following deployment Feeling "on edge“ Have to do a perimeter check if woken

Transition DifficultiesTransition Difficulties Continuously training Continuously training

for warfor war Routine/StructureRoutine/Structure

Constant vigilance Constant vigilance

Constantly “hitting the Constantly “hitting the gas”gas”

When faced with When faced with fight/flight-FIGHTfight/flight-FIGHT

Little training for peaceLittle training for peace No routine, no external No routine, no external

structurestructure Increased perception Increased perception

of threatof threat No strategies to “hit No strategies to “hit

the brakes”the brakes” Reactions scare Reactions scare

othersothers

Differences with members of Differences with members of National Guard & ReservistsNational Guard & Reservists

Many have established families and Many have established families and careers (that get disrupted by careers (that get disrupted by deployment)deployment)

Families do not live on military bases Families do not live on military bases (with support)(with support)

Do not have regular contact with fellow Do not have regular contact with fellow soldiers after return (limited support soldiers after return (limited support system)system)

Substance AbuseSubstance AbuseSeal et al. (2011)Seal et al. (2011) Drug and Alcohol Dependence Drug and Alcohol Dependence

About 1 in 10 had an alcohol use disorder and About 1 in 10 had an alcohol use disorder and 1 in 20 had a drug use disorder1 in 20 had a drug use disorder

Risk Factors: Risk Factors: Male sex, age under 25, never-married or divorced Male sex, age under 25, never-married or divorced status, and greater combat exposurestatus, and greater combat exposure

Almost 3/4 also received a diagnosis of PTSD Almost 3/4 also received a diagnosis of PTSD or depression. or depression.

Those with PTSD or depression were about 4x Those with PTSD or depression were about 4x more likely to have a drug or alcohol problem. more likely to have a drug or alcohol problem.

Close to those seen in Vietnam Veterans.Close to those seen in Vietnam Veterans.

Family ProblemsFamily Problems Sayers, Farrow, Ross & Olsin, 2009Sayers, Farrow, Ross & Olsin, 2009

Journal of Clinical PsychiatryJournal of Clinical Psychiatry

40.7% feeling like a guest in their house40.7% feeling like a guest in their house 25.0% children are not warm toward them 25.0% children are not warm toward them

or are afraid of themor are afraid of them 37.2% not sure of their family role37.2% not sure of their family role

Among separated partnersAmong separated partners 53.7% shouting, pushing or shoving53.7% shouting, pushing or shoving 27.6% partner is afraid of them27.6% partner is afraid of them

N=199N=199

Military Mindset/Academic MindsetMilitary Mindset/Academic Mindset

FunctionalFunctional Practical-Get er’ Practical-Get er’

DoneDone Subject ExpertSubject Expert Minimize DebateMinimize Debate Overcome Overcome

ObstaclesObstacles Accomplish the Accomplish the

Mission Mission

AbstractAbstract Thoughts and IdeasThoughts and Ideas Everyone’s opinionEveryone’s opinion Invite DiscussionInvite Discussion Discussion Discussion

Enhances Enhances Embrace the Embrace the

JourneyJourney

War Zones Require a Unique War Zones Require a Unique Set of Skills & Behaviors Set of Skills & Behaviors

James Monroe, Ed.D. Boston VAJames Monroe, Ed.D. Boston VA

WAR ZONE SKILLSWAR ZONE SKILLS Vigilance/DistrustVigilance/Distrust Chain of commandChain of command Mission OrientationMission Orientation

Act, then thinkAct, then think Numb or control Numb or control

emotions emotions Avoid closeness Avoid closeness

HOME SKILLSHOME SKILLS TrustTrust CooperationCooperation Juggling Multiple Juggling Multiple

ResponsibilitiesResponsibilities Think, then actThink, then act Express feelingsExpress feelings

Create intimacyCreate intimacy

Stress Injuries Occur When Stress Is Too Stress Injuries Occur When Stress Is Too Intense or Lasts Too LongIntense or Lasts Too Long CAPT W. Nash, USNCAPT W. Nash, USN

AdaptationAdaptation– A gradual processA gradual process– Can be traced over timeCan be traced over time– Individual remains in Individual remains in

controlcontrol– ReversibleReversible

InjuryInjury– May be more abruptMay be more abrupt– A derailment, change in selfA derailment, change in self– Individual loses controlIndividual loses control– Irreversible (though can heal)Irreversible (though can heal)

Three Mechanisms of Stress InjuryThree Mechanisms of Stress Injury

TRAUMATRAUMATRAUMATRAUMA

• An impact injury

• Due to events involving terror, horror, or helplessness

GRIEFGRIEFGRIEFGRIEF

• A loss injury• Due to the loss

of people who are cared about

FATIGUEFATIGUEFATIGUEFATIGUE

• A wear-and-tear injury

• Due to the accumulation of stress over time

COMBAT / OPERATIONAL COMBAT / OPERATIONAL STRESSSTRESS

COMBAT / OPERATIONAL COMBAT / OPERATIONAL STRESSSTRESS

Operational Stress Injuries Correlate Operational Stress Injuries Correlate with DSM-IV Diagnoseswith DSM-IV Diagnoses

Operational Stress Injuries Correlate Operational Stress Injuries Correlate with DSM-IV Diagnoseswith DSM-IV Diagnoses

TRAUMATRAUMATRAUMATRAUMA GRIEFGRIEFGRIEFGRIEFFATIGUEFATIGUEFATIGUEFATIGUE

Combat / Operational StressCombat / Operational StressCombat / Operational StressCombat / Operational Stress

PTSDPTSDPTSDPTSD

AlcoholAlcoholAlcoholAlcohol DrugsDrugsDrugsDrugs

DepressionDepressionDepressionDepression AnxietyAnxietyAnxietyAnxietyAngerAngerAngerAnger

Prepared by

Capt. William Nash, MC, USN

HQ, Marine Corps

Combat Stress PTSDCombat Stress PTSD Typical Reactions Mild/Moderate/SevereTypical Reactions Mild/Moderate/Severe to Combat Experiences to Combat Experiences

What Causes PTSD?What Causes PTSD?Risk FactorsRisk Factors

Intensity of trauma Intensity of trauma exposureexposure

Frequency of trauma Frequency of trauma exposureexposure

Killing Killing Prior traumatic eventsPrior traumatic events Combat verses Combat verses

Combat SupportCombat Support

Poor LeadershipPoor Leadership Lack of support Lack of support

(family, friends, etc.)(family, friends, etc.) Context/MeaningContext/Meaning Transition (military to Transition (military to

civilian life)civilian life) Avoidance of trauma Avoidance of trauma

related thoughts, related thoughts, memories or activitiesmemories or activities

What Causes PTSD?What Causes PTSD?Protective FactorsProtective Factors

TrainingTraining Experience Experience

(Habituation)(Habituation) Unit cohesion/ Unit cohesion/

leadershipleadership ExpectationsExpectations

Sense of purpose in Sense of purpose in suffering of self suffering of self and/or fellow service and/or fellow service membersmembers

Support on return Support on return ResilienceResilience

DSM-IV Criteria for Post Traumatic DSM-IV Criteria for Post Traumatic Stress Disorder (PTSD)?Stress Disorder (PTSD)?

Life threatening situation(s)Life threatening situation(s) Strong psychological reaction, e.g. intense Strong psychological reaction, e.g. intense

fear, helplessness, or horrorfear, helplessness, or horror

About 2/3 of combat veterans have at About 2/3 of combat veterans have at least one situation that was very least one situation that was very frightening, about 10-20% have PTSDfrightening, about 10-20% have PTSD

DSM-IV Criteria for PTSDDSM-IV Criteria for PTSD

DSM-5 Criteria ADSM-5 Criteria A

Exposure to actual or threatened death, Exposure to actual or threatened death, serious injury or sexual violation. The serious injury or sexual violation. The exposure to actual or threatened death, exposure to actual or threatened death, serious injury or sexual violence in one or serious injury or sexual violence in one or more of the ways:more of the ways:

DSM-5 Criterion ADSM-5 Criterion A

1.1. Directly experiencing the traumatic eventDirectly experiencing the traumatic event

2.2. Witnessing, in person, the event(s) as it Witnessing, in person, the event(s) as it occurred to othersoccurred to others

3.3. Learning that the traumatic event occurred to a Learning that the traumatic event occurred to a close family member or close friend. In cases close family member or close friend. In cases of actual or threatened death of a family of actual or threatened death of a family member or friend, the event(s) must have member or friend, the event(s) must have been violent or accidentalbeen violent or accidental

DSM-5 Criterion ADSM-5 Criterion A

4. Experiences repeated or extreme 4. Experiences repeated or extreme exposure to aversive details of the traumatic exposure to aversive details of the traumatic event(s) (e.g. first responders collecting event(s) (e.g. first responders collecting human remains; police officers repeatedly human remains; police officers repeatedly exposed to details of child abuse)exposed to details of child abuse)Note: Criterion 4A does not apply to Note: Criterion 4A does not apply to exposure through electronic media, exposure through electronic media, television, movies, or pictures, unless this television, movies, or pictures, unless this exposure is work-related)exposure is work-related)

DSM-5 Criteria for PTSDDSM-5 Criteria for PTSD

Four distinct diagnostic symptom clustersFour distinct diagnostic symptom clusters

Re-experiencingRe-experiencing AvoidanceAvoidance Negative cognitions and moodNegative cognitions and mood ArousalArousal

Re-experiencing symptomsRe-experiencing symptoms

Spontaneous memories of the traumatic Spontaneous memories of the traumatic eventevent

Recurrent dreams related to itRecurrent dreams related to it Flashbacks or other intense or prolonged Flashbacks or other intense or prolonged

psychological distresspsychological distress

Avoidance SymptomsAvoidance Symptoms

Avoidance refers to intentionally pushing Avoidance refers to intentionally pushing out of one’s mind:out of one’s mind: Distressing memoriesDistressing memories ThoughtsThoughts FeelingsFeelings Avoiding external reminders of the trauma. Avoiding external reminders of the trauma.

Negative Thinking and MoodNegative Thinking and Mood

Negative cognitions and mood represents Negative cognitions and mood represents myriad feelings:myriad feelings: Persistent and distorted sense of blame of Persistent and distorted sense of blame of

self or othersself or others Estrangement from othersEstrangement from others Markedly diminished interest in activitiesMarkedly diminished interest in activities (Less common) An inability to remember key (Less common) An inability to remember key

aspects of the event aspects of the event

Arousal SymptomsArousal Symptoms

Arousal is marked by:Arousal is marked by: Aggressive, reckless or self-destructive Aggressive, reckless or self-destructive

behaviorbehavior Sleep disturbancesSleep disturbances Hyper-vigilance or related problems. Hyper-vigilance or related problems.

Both “fight” and “flight” reactionsBoth “fight” and “flight” reactions

Mild TBI - PTSD: Mild TBI - PTSD: Overlapping Symptoms Overlapping Symptoms Scholten/CollinsScholten/Collins

Postconcussion Syndrome Postconcussion Syndrome (PCS)(PCS)

InsomniaInsomnia Memory ProblemsMemory Problems Poor concentrationPoor concentration DepressionDepression AnxietyAnxiety IrritabilityIrritability FatigueFatigue NoiseNoise//lightlight intoleranceintolerance DizzinessDizziness HeadacheHeadache

PTSDPTSD

InsomniaInsomnia Memory problemsMemory problems Poor concentrationPoor concentration DepressionDepression AnxietyAnxiety IrritabilityIrritability Re-experiencingRe-experiencing AvoidanceAvoidance Emotional numbingEmotional numbing

Successful RecoverySuccessful Recovery

Overcoming barriers to treatmentOvercoming barriers to treatment Assessing the problemAssessing the problem Normalizing reactionsNormalizing reactions Engaging in/Completing TreatmentEngaging in/Completing Treatment Aftercare, if neededAftercare, if needed

Barriers to treatmentBarriers to treatment

StigmaStigma Worry about impact on military or civilian Worry about impact on military or civilian

careercareer Worry about being seen as “crazy” or Worry about being seen as “crazy” or

“paranoid”“paranoid” Finding resourcesFinding resources Negotiating bureaucraciesNegotiating bureaucracies Getting to treatment (low wage jobs, no paid Getting to treatment (low wage jobs, no paid

time off)time off)

Assessing the problemAssessing the problem

Sometimes well meaning, caring people Sometimes well meaning, caring people can push a combat veteran to talk…can push a combat veteran to talk…

Triggers either fear and distance or Triggers either fear and distance or overexposure and feeling overwhelmedoverexposure and feeling overwhelmed

““I thought talking about it was going to I thought talking about it was going to make me feel better, but instead…”make me feel better, but instead…”

Normalizing reactionsNormalizing reactions

You are not crazyYou are not crazy It makes sense to be watchful, guarded and It makes sense to be watchful, guarded and

alert (You are not paranoid)alert (You are not paranoid) You developed skills to help you adapt to a You developed skills to help you adapt to a

difficult and dangerous environmentdifficult and dangerous environment These skills saved your life in war zone, so These skills saved your life in war zone, so

may seem essential to keepmay seem essential to keep These skills may not be working so well for These skills may not be working so well for

you nowyou now

Engaging in treatmentEngaging in treatment

This is often a big stepThis is often a big step Outcome research for substance abuse Outcome research for substance abuse

shows equal improvement whether self shows equal improvement whether self referred or “a nudge from the judge”referred or “a nudge from the judge”

Matching the person with a treatment that Matching the person with a treatment that is acceptable to them is key is acceptable to them is key

Treatment OptionsTreatment Options

Symptom ManagementSymptom Management More acceptable to More acceptable to

many veteransmany veterans Easy to “try out”Easy to “try out” Gives practical, “how Gives practical, “how

to” skills and fast to” skills and fast relief (e.g. with meds)relief (e.g. with meds)

Best approach for Best approach for limited symptoms limited symptoms (e.g. nightmares)(e.g. nightmares)

Trauma FocusedTrauma Focused Research strongly Research strongly

indicates best choice indicates best choice for improvement (with for improvement (with Evidenced-Based Evidenced-Based Psychotherapies)Psychotherapies)

SystematicSystematic Time limited (usually Time limited (usually

12-15 sessions)12-15 sessions)

Avoidance and TreatmentAvoidance and Treatment

Since avoidance is a symptom of PTSD, Since avoidance is a symptom of PTSD, the person will be tempted to cancel or not the person will be tempted to cancel or not show for sessionsshow for sessions

Completing treatment is difficult, especially Completing treatment is difficult, especially if engaged in trauma focused treatmentif engaged in trauma focused treatment

Free Self Help Treatment Free Self Help Treatment OptionsOptions

Afterdeployment.orgAfterdeployment.org Put together by the Dept of Defense and Put together by the Dept of Defense and

offers help for sleep, anger, PTSD, family offers help for sleep, anger, PTSD, family issues, etc.issues, etc.

Maketheconnection.netMaketheconnection.net Developed by the VA to help veterans Developed by the VA to help veterans

connect with other veterans from the same connect with other veterans from the same era with similar issues.era with similar issues.

Mobile App: PTSD Coach Mobile App: PTSD Coach ncptsd.govncptsd.gov

Learning Alternative Ways to Learning Alternative Ways to RespondRespond

Respond rather than react Respond rather than react Changing “muscle memory”Changing “muscle memory”

Learn assertive versus passive or Learn assertive versus passive or aggressive responsesaggressive responses

What makes reactions better or What makes reactions better or worse?worse?

Worse:Worse: Looking at situations Looking at situations

as if you are still in as if you are still in war zonewar zone

Insisting immediate Insisting immediate improvementimprovement

Assuming that all Assuming that all alarming reactions alarming reactions are “true alarms”are “true alarms”

Becoming a hermitBecoming a hermit

Better:Better: Reminding yourself you Reminding yourself you

are not in a war zoneare not in a war zone Staying in situations Staying in situations

long enough to allow long enough to allow the alarm reaction to the alarm reaction to go downgo down

Being around people Being around people even though it may feel even though it may feel awkward at firstawkward at first

Evidence-Based TherapiesEvidence-Based Therapies

  Prolonged Exposure (PE) and Cognitive Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are treatments Processing Therapy (CPT) are treatments endorsed by the Veterans Administration endorsed by the Veterans Administration as evidence-based treatments for PTSD.as evidence-based treatments for PTSD.

EMDR is a promising treatment for PTSD. EMDR is a promising treatment for PTSD.

A Qualification (Hoge-2010)A Qualification (Hoge-2010)

Effect sizes Effect sizes Meds (59% recovery versus 39% placebo)Meds (59% recovery versus 39% placebo) Psychotherapy (41% Exposure Therapy Psychotherapy (41% Exposure Therapy

versus 29% Supportive (no specific)versus 29% Supportive (no specific) CPT 3 versus 40%CPT 3 versus 40% Partial versus Complete Recovery from Partial versus Complete Recovery from

PTSD may be the case for many veteransPTSD may be the case for many veterans

Prolonged Exposure (PE)Prolonged Exposure (PE)

PE is a 10-15 session program that is done in PE is a 10-15 session program that is done in 90 minute individual sessions. There is also 90 minute individual sessions. There is also considerable out of session “homework” considerable out of session “homework” involved. involved.

15+ Randomized Controlled Trials/Many 15+ Randomized Controlled Trials/Many “Effectiveness” studies“Effectiveness” studies

The Veteran monitors symptoms by completing The Veteran monitors symptoms by completing a symptom checklist (PCL-M).a symptom checklist (PCL-M).

www.ptsd.va.gov/public/pages/www.ptsd.va.gov/public/pages/prolongedprolonged--exposureexposure--therapytherapy.asp.asp

Prolonged Exposure (PE)Prolonged Exposure (PE)

PE is a treatment that helps survivors of PE is a treatment that helps survivors of trauma to emotionally process their trauma to emotionally process their experiences. experiences.

Veterans are helped to confront their trauma Veterans are helped to confront their trauma memory. This is done to decrease their fear and memory. This is done to decrease their fear and anxiety. An example of this is the rider that is anxiety. An example of this is the rider that is encouraged to “get back on the horse” after encouraged to “get back on the horse” after being thrown off. The rider overcomes the fear of being thrown off. The rider overcomes the fear of being thrown again. This also prevents the fear being thrown again. This also prevents the fear from affecting other areas of his life.from affecting other areas of his life.

PE – 2 main componentsPE – 2 main components

Imaginal exposure: Imaginal exposure: Client recounts Client recounts their worst traumatic event in detail their worst traumatic event in detail repeatedly in session (and daily listens to repeatedly in session (and daily listens to tapes of themselves out of session)tapes of themselves out of session)

In-vivo exposure: In-vivo exposure: Client develops a Client develops a hierarchy of avoided situations and exposes hierarchy of avoided situations and exposes themselves to these situations for 30-45 themselves to these situations for 30-45 minutes daily (starting with situations that minutes daily (starting with situations that are 30 on a 0-100 scale)are 30 on a 0-100 scale)

Resources for Therapist and Resources for Therapist and PatientPatient

Prolonged Exposure Therapy for PTSD: Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Emotional Processing of Traumatic Experiences Therapist Guide Experiences Therapist Guide (Treatments That (Treatments That Work) Work) Edna Foa, Elizabeth Hembree, Barbara Olaslov RothbaumEdna Foa, Elizabeth Hembree, Barbara Olaslov Rothbaum

Reclaiming Your Life from a Traumatic Reclaiming Your Life from a Traumatic Experience: A Prolonged Exposure Experience: A Prolonged Exposure Treatment Program Workbook (Treatments Treatment Program Workbook (Treatments That Work) That Work) Barbara Rothbaum, Edna Foa, Barbara Rothbaum, Edna Foa, Elizabeth HembreeElizabeth Hembree

PE app (ncptsd.gov) PE app (ncptsd.gov)

Center for Deployment PsychologyCourse 113 (Online): Cognitive Processing Therapy (CPT) for PTSD in Veterans and Military Personnel

National Center for PTSDThe Course Cognitive Behavioral Psychotherapies for PTSD outlines the components and empirical support for two evidence-based treatments: Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT).

Cognitive Processing Therapy Cognitive Processing Therapy (CPT)(CPT)

12 Session structured psychotherapy approach12 Session structured psychotherapy approach 7 Randomized Controlled Trials/Many 7 Randomized Controlled Trials/Many

“Effectiveness” studies“Effectiveness” studies Based on a social cognitive theory of PTSD that Based on a social cognitive theory of PTSD that

focuses on how the traumatic event(s) is construed focuses on how the traumatic event(s) is construed and coped with by a person who is trying to regain and coped with by a person who is trying to regain a sense of mastery and control in his/her lifea sense of mastery and control in his/her life

Based on the Cognitive Therapy Model developed Based on the Cognitive Therapy Model developed by Aaron Beck, M.D.by Aaron Beck, M.D.

Also utilizes therapeutic writing strategies Also utilizes therapeutic writing strategies developed by James Pennebaker, Ph.D.developed by James Pennebaker, Ph.D.

Cognitive Processing TherapyCognitive Processing Therapy

CPT is a 12 session program that can be CPT is a 12 session program that can be done in individual (much research basis) done in individual (much research basis) or group sessions (emerging research or group sessions (emerging research basis).basis).

There is also some out of session There is also some out of session “homework” involved-writing about the “homework” involved-writing about the trauma and writing about one’s thoughts trauma and writing about one’s thoughts and emotions. This is reviewed with the and emotions. This is reviewed with the therapist in session.therapist in session.

Cognitive Processing TherapyCognitive Processing Therapy(CPT)(CPT)

CPT begins with education about trauma. CPT begins with education about trauma. It looks at the normal reactions to the It looks at the normal reactions to the trauma. The therapy then moves to look trauma. The therapy then moves to look at and evaluate your thinking and beliefs at and evaluate your thinking and beliefs about the events. You are finally asked to about the events. You are finally asked to "talk" about your experiences by writing "talk" about your experiences by writing about them. You read them to the about them. You read them to the therapist (and/or group members). therapist (and/or group members).

CPTCPT

Reading about your trauma is followed by Reading about your trauma is followed by a discussion of "stuck points." Stuck a discussion of "stuck points." Stuck points are memories or thoughts you have points are memories or thoughts you have been unable to move past. They continue been unable to move past. They continue to impact on your ability to live a full life. to impact on your ability to live a full life. The Veteran monitors symptoms by The Veteran monitors symptoms by completing a check list (PCL-M). completing a check list (PCL-M).

Treatment Model: Cognitive Treatment Model: Cognitive Processing Therapy (CPT)Processing Therapy (CPT)

Focus on the Focus on the contentcontent of cognitions of cognitions and the effect that distorted cognitions and the effect that distorted cognitions have upon emotional responses and have upon emotional responses and behaviorbehavior

Sees PTSD as a disruption or stalling Sees PTSD as a disruption or stalling out of a normal recovery process – and out of a normal recovery process – and works to determined what interfered works to determined what interfered with normal recoverywith normal recovery

Eye Movement Desensitization and Eye Movement Desensitization and Reprocessing (EMDR)Reprocessing (EMDR)

EMDR is a treatment for traumatic EMDR is a treatment for traumatic memories that involves elements of memories that involves elements of exposure therapy and cognitive behavioral exposure therapy and cognitive behavioral therapy, combined with techniques like therapy, combined with techniques like eye movements or hand taps that cause eye movements or hand taps that cause the patient’s attention to alternate back the patient’s attention to alternate back and forth across the midline. and forth across the midline.

EMDR Outcome StudiesEMDR Outcome Studies

EMDR has been shown to be more EMDR has been shown to be more effective than placebo wait list, effective than placebo wait list, psychodynamic, relaxation, or supportive psychodynamic, relaxation, or supportive therapies. However, research comparing therapies. However, research comparing EMDR to other CBT therapies shows EMDR to other CBT therapies shows significantly better results have been significantly better results have been maintained with CBT than EMDR, maintained with CBT than EMDR, particularly over time.particularly over time.

AftercareAftercare

Many veterans will benefit from ongoing Many veterans will benefit from ongoing supportsupport

This can be community based or may be This can be community based or may be part of a formal mental health treatment part of a formal mental health treatment programprogram

OEF/OIF/OND Readjustment ProgramOEF/OIF/OND Readjustment Program(405) 456-2855(405) 456-2855

Carly Hobbs, Program Support AssistantCarly Hobbs, Program Support Assistant

Yan Feng, M.D., Medical DirectorYan Feng, M.D., Medical Director

Gina Pierce, M.D., PsychiatristGina Pierce, M.D., Psychiatrist

Shannon Thomas, M.D., PsychiatristShannon Thomas, M.D., Psychiatrist

Steve Scruggs, Psy.D., Team LeaderSteve Scruggs, Psy.D., Team Leader

steven.scruggs@va.govsteven.scruggs@va.gov

Susan Shead, LCSW, Social WorkerSusan Shead, LCSW, Social Worker

Amber Ward, LCSW, Social WorkerAmber Ward, LCSW, Social Worker

Rob Braese, Ph.D., Staff PsychologistRob Braese, Ph.D., Staff Psychologist

Anna Colston, PA-C, Physician AssistantAnna Colston, PA-C, Physician Assistant

Regan Settles, Ph.D., Postdoctoral Fellow Regan Settles, Ph.D., Postdoctoral Fellow