Psychotherapeutic Treatment of Appalachian Combat

Veterans with PTSD

Myra Qualls Elder, Ph.D.James H. Quillen Veterans Affairs Medical Center, Mountain Home,

TN

Post Traumatic Stress Disorder• Trauma: Outside normal range of

human experience• Re-experiencing the trauma:

– Nightmares– Intrusive memories– Flashbacks– Distress when faced with triggers

PTSD Symptoms: Avoidance• Avoidance of thoughts, feelings,

people, places assoc. w/ the trauma• Detachment/numbing/estrangement• Some amnesia of trauma• Foreshortened future• Loss of interest in activities

PTSD Symptoms: Arousal

• Insomnia/broken sleep• Irritability/anger• Problems concentrating• Hypervigilance• Exaggerated startle response

Symptoms listed in DSM-IV-TR

Proposed Changes To PTSD Diagnosis in DSM-V (2013)• Event experienced by close

relative/friend• Do not need to feel

fear/helplessness/horror• Repeated exposure to distressing

details of events of others (police officer, for ex.)

• Criterion D: negative thoughts, moods, or evaluations of self and/or world

• (Thanks to Dr. Tom Stoss for this information)

Appalachian Veteran-Specific Diagnostic Questions• When do you do your grocery

shopping?• Do you ever eat at a restaurant?

Where do you sit?• Is there a gun in your bedroom? How

many guns are in your house?• How many times a night do you

check your window/door locks?• What do you do on July 4th?

PTSD Prevalence Data

• Community stats: current PTSD rates = 5-6% men, 10-12% women

• National Vietnam Veterans Readjustment Study (mid-1980s): then-current PTSD rates = 15% men, 8% women

• Lifetime rates: 30% men, 25% women (cited in Friedman, 2004)

PTSD Prevalence Data II

• Operation OIF/OEF: 2008 Rand Institute Study: 18.5% diagnosed with PTSD

• 35% of Iraq war vets accessed MH svcs in the year after returning home (Hoge, et al., 2006)

• 2001-2005, N = 103,788 OEF/OIF vets:

25% received MH dxs, 56% of those rec’d

2 MH dxs, skewed toward vets 18-24 (Seal, et al., 2007)

National Center for PTSD Data• 12% to 20% soldiers and Marines had

PTSD after serving in Iraq• 7% to 15% had depression after

serving in Iraq or Afghanistan• 1 in every 4 soldiers or Marines

reported using alcohol more than they meant to

• 1 of every 3 returning soldiers treated by the VA for MH issues

Now what?

• Establish trust: necessary condition• Must be present: minimize

distraction, pay attention, have two channels open

• Must be engaged: reflective is good, responsive is better, avoid being reactive

• Patient must feel as safe as possible, physically and emotionally (ex. windows, pagers, intrusions)

Conditions Necessary for Tx

• Time: no substitute for this, need it for trust to develop

• Maslow’s Triad: can it be taught?• Culture/Context: military training,

masculinity, Appalachian (“Alvin York Syndrome”)

• Military service an honorable way to individuate from an enmeshed family

From Sebastian Junger’s 2010 book, “War,” about the 173rd in Afghanistan• “War is supposed to feel bad because

undeniably bad things happen in it, but for a 19-y.o. at the working end of a .50 cal during a firefight that everyone comes out of okay, war is life multiplied by some number that no one has ever heard of. In some ways, 20min of combat is more life than you could scrape together in a lifetime of doing something else.”

Early Therapeutic Tasks

• Orientation to therapy• Rationale for therapy: “crude oil to

gasoline” and reducing avoidance• Possible negative and positive effects

of therapy (this is informed consent)• Educate about PTSD & talk to

spouse.• Analogy of physical therapy: “frozen

shoulder”

The “A” Problems in PTSD

• Anger• Alcohol • Avoidance

Early and Mid-Tx Tasks

• Therapeutic deed, not just word• Assessing and creating coping skills

FIRST: distraction, relaxation, music, hobbies, social support, exercise

• Then, constructing the trauma narrative

• Hearing the hard stuff and staying present

• Dealing with current life stressors/issues

Middle and Later Therapy Tasks• Decreasing affective reactivity: must

learn words for emotions (visual to verbal)

• Decreasing maladaptive behaviors• Decreasing “stinking thinking:” with

vets, all-or-nothing thinking and paranoia very common

• Increasing some integration into society

• Increasing self-efficacy: homework

PTSD is a chronic condition

• Balance instillation of hope with realistic view: there will be exacerbations

• Current stress, medical problems, travel away from home, media exposure to ongoing war, substance use/abuse

• Anniversary reactions• The body remembers

Potential Pitfalls

• Secondary traumatization• Patient dropping out in middle of

trauma narrative• Unrealistic expectations• Acting out (patient, not therapist)• Exhaustion (therapist and patient)

Psychologist Self-Care

• Balance case-load• Peer supervision and/or occasional

therapy to “offload baggage”• Stable and balanced life away from

work• Seeing work as meaningful

Does Therapy Work?

• 40 years of data on therapy: patient’s rating of the alliance is the best predictor of engagement and outcome

• All therapy models show that the most change occurs early in the therapeutic process

• Therapy accounts for 13% of variance for change (Wampold, 2001, cited by Miller, 2007)

PTSD Therapy Outcome Data• Limited data, focuses on:• Exposure-based therapies• Cognitive Behavioral Therapy• EMDR• Small-scale studies, different

populations (rape and accident victims, vets), modest treatment gains/effect sizes

Difficult to Measure Prevented Behaviors

• Who did not commit suicide?• Who did not commit homicide?• Who did not drink/use drugs?• Who did not abuse family members?

• “Maybe the ultimate wound is the one that makes you miss the war you got it in.”

- Sebastian Junger, “War”