Special Considerations in the Psychotherapeutic Treatment of

Special Considerations in the
Psychotherapeutic Treatment of
Appalachian Combat Veterans
with PTSD
Myra Qualls Elder, Ph.D.
James H. Quillen Veterans Affairs
Medical Center, Mountain Home, TN
•  The views expressed are my own and
do not represent the official views of
the Veteran’s Health Administration
(VHA). (They wouldn’t let me out to
do this presentation unless I put in
this slide.)
•  Recognize the special challenges posed by
Appalachian and military cultural identities
•  Become familiar with rates of substance
use/abuse among combat veterans, and
how this affects treatment
•  Learn about VA-endorsed Evidence-Based
Treatments (EBTs) for PTSD
ARC’s Map of Appalachia
You are 19…
•  New Category: Trauma- and
Stressor-Related Disorders
•  Inclusive of “trauma by proxy”
•  More descriptive of negative cognitive
and emotional states as sxs
(American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition. Arlington, VA, American Psychiatric Association, 2013. Web. [access date: 1 June 2013].
PTSD Symptoms After Exposure
•  Intrusion Sxs: memories, dreams,
flashbacks, distress from triggers
•  Avoidance Sxs
•  Negative cognitive/emotional states (this
is the new sx category in DSM-V): guilt,
shame, pervasively negative thinking,
detachment, estrangement, anhedonia
PTSD Symptoms Continued
•  Arousal: Anger, reckless/self-destructive
behavior (this is new), insomnia, etc.
(American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Web. [access
date: 1 June 2013]. dsm.psychiatryonline.org)
•  The 4 A’s of PTSD: Anger, Alcohol (or
opioids, or benzos),
Avoidance, Alexithymia
Veteran-Specific Dx 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? Your
vehicle? Do you keep them loaded?
•  How many times a night do you check
your window/door locks?
•  What do you do on July 4th?
PTSD Prevalence Data
•  US projected lifetime risk at age 75 =
8.7%, using DSM-IV criteria (DSM-V)
•  12-month prevalence among US adults =
•  National Vietnam Veterans Readjustment
Study (mid-1980s): then-current PTSD
rates = 15% men, 8% women
•  Rates vary across groups and cultures
PTSD Prevalence Data II
•  Millennium Cohort Study: 150K military
personnel, data collected 2001-2012
•  New onset, deployed, non-combat: 2.1%
•  New onset, deployed, combat: 8.7%
•  Current best guess: non-VA users: 15%
•  VA users: almost 25%
•  More sxs among Nat’l Guard and
•  Prevalence stats here on co-morbidity
of PTSD and SUDs
Opioids –
Evidence-Based Treatments
•  Prolonged Exposure (PE)
•  Cognitive Processing Therapy (CPT)
•  Cognitive Therapy (CT)
•  Eye Movement Desensitization and
Reprocessing (EMDR)
•  Stress Inoculation Training (SIT)
•  Time-limited, structured txs
Prolonged Exposure
•  90-minutes
•  1:1
•  8-15 sessions
•  Education/Coping
•  SUDs/in vivo
•  Imaginal exposure (starts
in Session #3)
Emotional processing
Homework every session
Narrow down exposure to
the “hot spots”
Final session: process
the entire memory again
Does it work?
•  Yes. Meta-analysis of 13 randomized
controlled studies showed that the
average PE patient fared better than 86%
of patients in control conditions at post-tx.
•  The catch: no significant diff. b/t this and
other EBTs
•  Another catch: Drop-out rates from
17%-52%; N = 65 vets, and 22 dropped
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, optimal # of sessions is
•  Genuineness/Positive Regard/Empathy
•  Culture/Context: Trained to kill,
“programmed,” military mindset,
masculinity, Appalachian…
•  Military service = honorable way to
individuate from 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)
•  Education about PTSD: “You are not
going crazy.” Talk to spouse.
•  Analogy of physical therapy: “frozen
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; shame, blame, guilt
•  Increasing some integration into society
•  Increasing self-efficacy: homework
Recovery vs. Cure
•  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
•  LGBT veterans
Potential Pitfalls
•  Secondary traumatization
•  Patient dropping out in middle of trauma
•  Unrealistic expectations
•  Acting out (patient, not therapist)
•  Exhaustion (therapist and patient)
Therapist 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: Smoky
Mountain Service Dogs:
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
•  Therapy accounts for 13% of variance for
change (Wampold, 2001, cited by Miller, 2007)
Difficult to Measure Prevented
•  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
- Sebastian Junger, “War”