Working with Veterans with Trauma & PTSD

1. Presented July 7, 2016 as part of the Grant per Diem educational training series for staff Working with Veterans with Trauma & PTSD Karen Krinsley, Ph.D. PTSD Section Co-Chief, VA Boston Healthcare System & National Center for PTSD

2. Outline of Talk • Brief review of PTSD - DSM V & implications of the diagnosis • What makes PTSD symptoms better / worse? • Practical ideas for helping • Effective treatments

3. How can YOU help a Veteran with PTSD? • Task: Think about what you do now • What is working? • What has been less helpful? • Shared wisdom is the best! • Comments welcome

4. What does PTSD look like? • No one clinical picture but not like it is shown on television/movies • Can’t stereotype, although it’s done • There are some “hallmarks” • Nightmares • Poor sleep • Anger • Numbness or sadness • Avoidance of groups

5. The technical diagnosis of PTSD —And why it is important • Misdiagnosis is common • Misunderstandings are common • Great reason not to focus on other issues • Serious but treatable when it is present • Typically NOT present alone

6. Important to Remember PTSD ≠ TRAUMA and TRAUMA ≠ ANYTHING bad

7. PTSD ≠ Trauma ≠ Anything bad • Traumas do not always lead to PTSD • Traumas may lead to PTSD, but then the person recovers • And, many bad things happen to people, affecting them deeply, that are not “trauma”

8. PTSD (DSM V): A Cluster of Symptoms • Trauma (The “Stressor”) • Intrusions • Avoidance • Alterations in mood or cognition E Alterations in arousal & reactivity

9. Some PTSD changes in DSM V • Diagnosis more clearly defined • Dissociative type • Delayed type • Negative beliefs & expectations • Distorted blame of self or others

10. PTSD Criterion A Stressor • exposure to actual or threatened death, serious injury or sexual violation. • experiences directly, witnesses,learned about (occurred to close family or close friend) or experiences repeated or extreme exposure to aversive details usually professionally • clinically significant distress or impairment

11. Criterion B: Reexperiencing/Intrusions • Recurrent, involuntary, & intrusive memories • Traumatic nightmares • Dissociative reactions • Intense or prolonged distress after exposure to traumatic reminders • Marked physiologic reactivity after exposure to trauma-related stimuli

12. Criterion C: Avoidance • Trauma-related thoughts or feelings. • Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

13. Criterion D: Negative Alterations in Cognitions & Mood • Inability to recall key features • Persistent (& often distorted) negative beliefs and expectations about oneself or the world • Persistent distorted blame of self or others • Persistent negative trauma-related emotions • Markedly diminished interest in (pre-traumatic) significant activities. • Feeling alienated from others (e.g., detachment or estrangement). • Constricted affect: negative

14. Criterion E: Alterations in Arousal & Reactivity • Irritable or aggressive behavior • Self-destructive or reckless behavior • Hypervigilance • Exaggerated startle response • Problems in concentration • Sleep disturbance

15. How common is PTSD? • 3.5% general population, current • 1.8% men • 5.2% women • Lifetime: 6.8% -- 3.6% men, 9.7% women (U.S. National Comorbidity Survey Replication 2001-03)

16. How common is PTSD? • Vietnam theater veterans: • 15.2% of men • 8.1% of women (National Vietnam Veterans Readjustment Study 1986-88) • Gulf War: 10% • OEF/OIF: 10-18% • Sexual assault survivors: roughly 30%

17. What puts you at risk for PTSD? • *Strength or severity of the stressor • Characteristics of the trauma • Greater perceived life threat • Feeling helpless • Unpredictable, uncontrollable • Previous history • Social support & life stress

18. What External Factors May Increase PTSD Symptoms? • Life Stress • Lack of Social Support • More generally, anything that triggers memories or other symptoms

19. Implications of PTSD • Greater risk of other disorders • 80% of people with PTSD have another diagnosis • Depression, SUD, Anxiety Disorders common • Greater unemployment • Relationship difficulties • Health problems • Generally, worse quality of life

20. Substance Use as a Dual Diagnosis with PTSD • May be self-medication • To forget • To be able to feel and enjoy life • To keep going • To regain that adrenaline “high” • As self-punishment • Becomes an independent addiction

21. What Promotes Resiliency? • Positive emotions, Emotion regulation, Cognitive flexibility, Coping style, Spirituality, Moral code AND • Social support • Having resilient role models • Purpose and meaning

22. Common Triggers in Residential Settings – and Ways to Reduce • TV Shows • Conversation topics • Disputes, Anger • Disrespect • Crowding • Behavior of other residents, may be well-meant

23. Common Triggers in Residences, continued • Not feeling safe at night • Locks? • Lights? • Noise (may or may not need) • Touching at night • Required outings • What else?

24. Reminder: Consider a “Trauma-Informed Milieu” • Structured but not authoritative or punishing • Everyone treated with respect and listened to • Setting is kept safe • Staff aware that residents may be traumatized

25. Positive Steps To Take • Always listen FIRST • Start with support • Take concerns seriously • Treat everyone as an adult

26. Positive Steps, continued • PTSD is an explanation (although not an excuse) • Do ask if they want to talk and acknowledge their military service • Don’t say “I understand” • Be alert for risk issues

27. Positive steps, cont’d. • Sleeping / Nightmares: No touching • No “fooling around”: Don’t sneak up on someone, don’t make sudden noises behind them • Understand the impact of TV • Consider special requests: Light, Noise, Large Groups

28. Anger Management: Useful Clinical Practice Guidelines • Develop lists of enjoyable activities • And promote participation • Promote sleep and relaxation • Avoid stimulants and other substances such as caffeine and alcohol • Address pain - highly linked to problems with anger and aggression

29. More Tips for Managing Anger • Confrontation probably NOT helpful • Try to understand the cause, both to help manage and to help yourself stay calm • Prepare ahead of time with the veteran if possible • Allow “escape”

30. Helping Veterans with TBI (practical ideas) • See “Anger” • Organizational help may be needed • Small datebook / cell phone • Calendars, instructions in visible places • Alarms, reminders

31. Stress Management • Can someone teach relaxation? • If not, use tapes! • Practice daily

32. Teaching Grounding • Focus on the world around you • Try an exercise with your staff • Check out exercises in books

33. “Complementary and Alternative Medicines” (CAM) • Recommendations from our veterans • Now being researched • Meditation • Yoga • Acupuncture

34. And Other Alternatives Recommended by Vets! • Contact with animals • Martial Arts • Fishing • Exercise • Massage (be careful with this one) • Reading / Self Help Books • Journaling

35. Motivating Vets for Treatment • Are there any role models? • Instilling hope • Encouraging but not forcing • Ask: What is stopping you?

36. Barriers to Getting Help • Vets with PTSD (and others) are often unaware of their problems • Problems may be obvious to those around them, but not to the Veterans • It helps to understand how/why the Vets could truly be unaware

37. Reasons for Lack of Awareness of Problems • Admitting problems = Weakness / Is Dangerous • Trauma Symptoms/Responses feel right, e.g. isolating, avoiding, all or nothing thinking • Lack of self worth and guilt = I don’t deserve to get better anyway

38. Additional Barriers to Getting Help • Stigma – can you help reduce? • Difficulty accessing • Fear • What would it mean to get better? Is it possible? • If I try to deal with this, I’ll start crying and never stop • It’s too late

39. Professional Help - Reminder • Know when to refer • Be knowledgeable about PTSD treatments and aware that they work • Encourage keeping appointments • Acknowledge that it will be HARD but it is worth it • Ask what the alternative is • Be wary of splitting

40. Work with Therapists! • The good ones welcome the opportunity • Speak with veteran about a Release of Information • Ask: What can we do to reinforce treatment? • Ask: Anything we should be aware of? • Working as a team is always better

41. Effective PTSD Treatments • State of the art treatment • Empirically validated treatments • Staged, stepped model of care • Safety • Trauma focus • Reconnection • Interdisciplinary • PTSD ≠ chronic mental illness

42. Treatment for PTSD • Cognitive Behavioral Treatments most effective psychotherapy treatments • Medication can be an effective treatment • Most evidence for Cognitive Processing Therapy and Prolonged Exposure • Most evidence for antidepressants

43. Stepwise Treatment Model:Stage 1 Safety • Suicide and Homicide prevention • Harm reduction for risky behaviors • Teach positive coping tools • Teach the role of avoidance • Group focus when possible, including: Seeking Safety, Understanding and coping with PTSD, Relaxation & Stress Mgmt, ACT, DBT modules & Anger Management, Wellness, & more

44. Stepwise Treatment Model:Stage 2 Trauma Focus • Core of PTSD treatment • Empirically validated treatments include Cognitive Processing Therapy and Prolonged Exposure • It works! Recovery is possible.

45. Trauma Focus Therapy • Many types • Core common elements • Exposure to the trauma in some form • Processing of the trauma • Results: Decreased avoidance, increased tolerance of distress, and ultimately decreased distress

46. Stepwise Treatment Model:Stage 3 Reconnection • Focus is on relationships • Reconnection with friends, family • Support groups, process groups, marriage and family work and more • Also may include Reparation

47. Comments on Veterans of Iraq & Afghanistan • National Guard OR Reserve OR Regular Military • Trauma is more acute or “raw” • Binge drinking or casual drug use • Pain medication • May be working and need different hours for treatment • Often have families and children, and may want or need them involved in treatment • May not want traditional treatments such as group therapy

48. More Information:National Center for PTSD Website • www.ptsd.va.gov • All types of information, for • Providers • Veterans • Families • General Public • Has online courses such as “Understanding PTSD” and much more

49. PTSD Consultation Program Reminder • One-on-one PTSD consultation for any VHA provider OR contractor • Free of charge • Speak directly with “expert” PTSD clinicians • Response usually within 24 hours • Easy to contact us: Call, email, or complete an online form