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Integrated Treatment of Substance Misuse and Co-occurring Disorders for Service members and Veterans. Michael DeFalco, Psy.D. Program Director The Military Wellness Program at Holliswood Hospital. Aynisa Leonardo, LCAT AT-R BC Program Coordinator

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slide1

Integrated Treatment of Substance Misuse andCo-occurring Disorders for Service members and Veterans

Michael DeFalco, Psy.D.

Program Director

The Military Wellness Program

at Holliswood Hospital

Aynisa Leonardo, LCAT AT-R BC

Program Coordinator

The Military Wellness and Family Reintegration Programs

at Holliswood Hospital and

Hope for the Warriors

accreditation
Accreditation

Nurse Accreditation Statement

PRIME Education, Inc. (PRIME®) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. PRIME® designates this activity for 6.0 contact hours.

Case Manager Accreditation Statement

The Commission for Case Manager Certification designates this educational activity for 6.0 contact hours for certified case managers.

NASW AccreditationThis program is Approved by the National Association of Social Workers (Approval #886602863-2041) for 13 Social Work continuing education contact hours.

disclosure policy
Disclosure Policy

PRIME Education, Inc. (PRIME®) endorses the standards of the ACCME, as well as those of the AANP, ANCC, and ACPE, which require everyone in a position of controlling the content of a CME/CE activity to disclose all financial relationships with commercial interests related to the activity content. CME/CE activities must be balanced, independent of commercial bias, and designed to improve quality in health care. All recommendations involving clinical medicine must be based on evidence accepted within the medical profession.

A conflict of interest is created when individuals in a position of controlling the content of CME/CE activities have a relevant financial relationship with a commercial interest which therefore may bias his/her opinion and teaching. This may include receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, stocks, or other financial benefits.

PRIME® will identify, review, and resolve all conflicts of interest that speakers, authors, course directors, planners, peer reviewers, or relevant staff disclose prior to an educational activity being delivered to learners. Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation. Disclosure information for speakers, authors, course directors, planners, peer reviewers, and/or relevant staff is provided with this activity.

Presentations that provide information in whole or in part related to non-FDA-approved uses of drugs and/or devices will disclose the unlabeled indications or the investigational nature of their proposed uses to the audience. Participants should refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings. Participants should verify all information and data before treating patients or employing any therapies described in this educational activity. The opinions expressed in the educational activity are those of the presenting faculty and do not necessarily represent the views of PRIME®, ACCME, AANP, ACPE, ANCC, or other relevant accreditation bodies.

learning objectives
Learning Objectives
  • Discuss evidence based and complimentary modalities to utilize in working with service members that have substance misuse issues.
  • Interpret the relationship between complex/adult onset trauma, and the development of substance misuse issues.

Michael Defalco, Psy.D. mdefalco1@libertymgt.com

slide6

Trends

  • Posttraumatic Stress Disorder (and co- morbid disorders- depression, anxiety, “behavioral acting out”)
  • Substance Abuse/Misuse
  • Suicide Attempts (completions)
  • Military Sexual Trauma
  • TBI
  • Chronic Pain

The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

slide7

The Army Substance Abuse Program- ASAP

c. The Army maintains the following principles:

(1) Abuse of alcohol or the use of illicit drugs by both military and civilian personnel is inconsistent with Army Values, the Warrior Ethos, and the standards of performance, discipline, and readiness necessary to accomplish the Army’s mission.

(2) Unit commanders must intervene early and refer all Soldiers suspected of being alcohol and/or drug abusers to the ASAP. The unit commander should recommend enrollment based on the Soldier’s potential for continued military service in terms of professional skills, behavior, and potential for advancement.

(3) The ASAP participation is mandatory for all Soldiers who are command referred and subsequently enrolled. Failure to attend a mandatory counseling session may constitute a violation of Article 86 of the Uniform Code of Military Justice (UCMJ).

(4) Soldiers who abuse alcohol and/or other drugs will be enrolled in the ASAP when such enrollment is clinically recommended. civilian corps members who abuse alcohol and/or other drugs may be enrolled in the ASAP when such enrollment is clinically recommended, space is available, and the employee agrees.

(5) Soldiers who fail to participate adequately in or to respond successfully to rehabilitation will be processed for administrative separation and not be provided another opportunity for rehabilitation except under the most extraordinary circumstances, as determined by the Clinical Director (CD) in consultation with the unit commander.

slide8

1–8. Army Values and the Warrior Ethos

Alcohol and drug abuse by Soldiers and civilian corps members can seriously damage their physical and behavioral

health, jeopardize their safety and the safety of those around them, and can lead to criminal and administrative

disciplinary actions. Alcohol and drug abuse is detrimental to a unit’s operational readiness and command climate and

is inconsistent with Army Values and the Warrior Ethos. The Army strives to be free of all effects of alcohol and drug

abuse.

slide9

Profile of Servicemembers Admitted to The Military Wellness Program

  • Represent a complex combination of the above-listed problems
  • 90% male
  • Average age 24 (ranges 20-30+)
  • Most deployed- OEF/OIF
  • 75% are dually-diagnoses with a significant behavioral health disorder (depression, anxiety, PTSD) and substance/alcohol abuse/dependence
  • Most are active-duty from Army, Marines, Navy, and Coast Guard

The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

slide10

Profile of Servicemembers Admitted to The Military Wellness Program

  • Cases are complicated by a myriad of psychosocial problems
    • Family
    • Financial
    • Service-related
    • Legal

The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

what is ptsd
What is PTSD?

A construct based on clinical and historical observations.

Initially codified in DSM-III (1980)- Vietnam Veterans

Current conceptualizations are changing as research explores various aspects of individuals reactions to traumatic stress throughout the lifespan.

Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

slide12

PTSD- Important, but Limited

  • Represents an important, but myopic conceptualization of the impact of traumatic stress on individuals
  • Does not capture the multitude of negative consequences associated with Trauma
  • Needs to be expanded to encompass the unique effects of Trauma experienced during childhood, especially Traumas of an interpersonal nature.

Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

slide13

PTSD- Critical Considerations

  • Drop the “Disorder”- a natural reaction to extreme stress
  • Resiliency
  • Dimensional, with different subtypes
  • PTS (COS) and its effects are treatable, not “life sentences”

Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

slide14

PTSD- Broad Strokes

  • Exposure to a potentially traumatic event
  • Persistent re-experiencing of the PTE
  • Persistent avoidance of reminders and a numbing of responsiveness
  • Persistent states of increased arousal

PTSD is a bio-psych-social-spiritual condition

slide16

Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study

Vincent J Felitti, MD, FACP

Robert F Anda, MD, MS

Dale Nordenburg, MD David S Williamson, MS

Allison M Spitz, MS Valerie Edwards, BA

Mary P Koss, PhD James S Marks, Ms, MPH

American Journal of Preventative Medicine, Vol 14, Issue 4, pages 245 – 258 (May 1998)

Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

ace study
ACE Study

N = over 17,000

Adult members of a large HMO in California

Average age = 57

Looked at relationship between 10 Adverse Childhood Events and current emotional, physical, and behavioral health.

slide18

ACE Study

The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

ace study2
ACE Study
  • midrange ACE score of 4 is associated with a 390% greater change of COPD as compared with an ACE of 0.

The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

ace study and depression
ACE Study and Depression

Persons with an ACE Score of 4 or more were 460% more likely to be depressed when compared to ACE of 0.

Historical risk of suicide was 1,220% greater for ACE 4: much higher for 5-6.

2/3 of suicide attempts were correlated with ACE.

The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

slide23

ACE Study and Alcoholism

The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

slide24

ACE Study

  • male with an ACE of 6 has 4,900% greater chance of IV drug use than ACE of 0.

The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

slide25

Population attributable riskassociated with early adversity:

•50% for drug abuse

•54% for current depression

•65% for alcoholism

•67% for suicide attempts

•78% for iv drug use.

ACES scores strongly related to many other health/functioning issues: hepatitis, heart disease, fractures, diabetes, obesity, alcoholism, occupational health and job performance

The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

why do aces have such a deleterious impact on health and functioning

Why do ACEs have such a deleterious impact on health and functioning?

The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

slide27

ACE Triangle

The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

slide29

Anda, Felitti, Bremmer, Walker, Whitfield, Perry, Dube and Giles. 2006. The enduring effects of abuse and related adverse experiences in childhood.European Archives of Psychiatry and Clinical neuroscience 256: 174-186

The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

slide30

Effect of Abuse and Neglect on the Corpus Callosum

Myelinated regions, such as the corpus callosum (CC) are potentially vulnerable to the impacts of early exposure to excessive levels of stress hormones, which suppress glial cell division critical for myelination.

CONTROL NEGLECT

The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

slide31

Attachment

  • Sets the template or “internal working models” for self and others
  • Example: infant and mother
  • Beatrice Beebe split screen studies
  • Ed Tronick: Still Face Studies
  • Others…
  • Neglect or abuse by caretakers disrupts this natural process and can have devastating consequences

The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

cdc risk factors for suicide and overlap with symptoms of ptsd continued
CDC Risk Factors For Suicide andOverlap With Symptoms of PTSD- continued
  • History of alcohol/substance use- continued:

- According to the CDC, the National Violent Death Reporting System examined toxicology reports of those who committed suicide in 13 states in 2004:

- 33.3% were positive for alcohol

- 16.4% were positive for opiates

- 9.4% were positive for cocaine

- 7.7% were positive for marijuana

- 3.9% were positive for amphetamines

slide33

Integration of Trauma and Addictions Theory

Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

slide34

The Window of Tolerance

High Arousal

Window of Tolerance

Optimal Arousal Zone

Low Arousal

Ogden and Minton (2000)

Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

slide35

Bi-Phasic Trauma Response

Emotional reactivity

Hypervigilance

Intrusive imagery

Obsessive/cyclical cognitive processing

Tension, shaking, ungrounded.

Hyperarousal: too much arousal to integrate

Window of Tolerance

Optimal Arousal Zone

Flat affect

Inability to think clearly

Numbing

Collapse

Hypoarousal:

too little arousal

to integrate

Ogden and Minton (2000)

Siegel (1999)

slide36

Trauma and Addiction:

A Paradoxical Way of Trying to Stay Safe

In the context of trauma, addictive

behavior is NOT a pleasure-seeking strategy, it is a survival strategy

  • To self-soothe and self-regulate
  • To reduce intrusive symptoms
  • To facilitate re-enactment symptoms
  • To combat helplessness
  • To treat hyper and hypo-arousal symptoms
  • To function and feel safer in the world

Fisher 2000 & 2005

Fisher, 2005

Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

slide37

How Substances “Medicate” Complex Trauma Symptoms

Hyperarousal Symptoms:

  • Induce relaxation and/or numbing effects,

initiate sleep, enhance mood, decrease anxiety and paranoia, dampen rage and aggression

(Alcohol, Marijuana, Opiates, Benzodiazepines)

Intrusive Symptoms:

  • Act as a “chemical barrier” to traumatic memory, block intrusive thoughts/images, decreasing traumatic memories and nightmares

(Heroin and opiates are the most effective for keeping intrusive symptoms at bay)

Fisher, 2000 & 2003

Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

slide38

How Substances “Medicate” Complex Trauma Symptoms

Hypoarousal Symptoms:

  • Increase alertness, confidence, sense of well-being
  • Counteract feelings of “deadness,” hopelessness, or weakness

(Cocaine, Speed, Stimulants, Alcohol)

Alcohol is the most versatile substance for addressing hypoarousal because at different dosages, it either induces numbing or counteracts it.)

Fisher, 2003

M ichael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

slide39

How Substances “Medicate” Complex Trauma Symptoms

Facilitate Re-enactment Symptoms:

  • Attract dangerous situations, risk-taking
  • Ensure that the individual is on and endorphin or adrenaline “high” that decreases trauma symptoms
  • (Alcohol and Cocaine)
  • Combat Helplessness
  • Increase feelings of power and control that battle
  • powerlessness
  • Facilitate social engagement
  • Allow individual to do activities in the community, be
  • with family, have intimate relationships
  • Fisher, 2000 & 2003
slide40

How Substances “Medicate” Complex Trauma Symptoms

Hyperarousal can be decreased by: alcohol, marijuana, heroin, overeating or restricting, binging, cutting, planning suicide, or self-harm

Hyperarousal

Window of Tolerance

Optimal Arousal Zone

Hypoarousal is decreased by: cocaine, crystal meth, high-risk behavior, purging, cutting, suicide planning, and sexual acting out

Hypoarousal

Ogden and Minton (2000)

Fisher (2004)

slide41

Mind-Body Focused Practices:

Re-Gaining Natural Control of One’s Physiology

  • Yoga- Trains somatic awareness, pain reduction,
  • thought clarity- Holistic pain reduction
  • Acupuncture- Targets symptoms directly, and non-
  • chemically (anxiety, chronic or acute pain, depression)
  • Meditation and Mindfulness- Teaches quieting response,
  • natural down regulation of Amygdala (stress center of
  • brain)
  • EMDR and Brainspotting- Uses somatic and visual cues
  • to promote neurological movement and non-verbal
  • trauma processing and release

The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

slide42

Trauma and Addictions- Processing Techniques

  • Prolonged Exposure- Strong evidence base. Effective in
  • treating symptoms of anxiety and hyper-arousal
  • In Vivo Desensitization- Opportunities to practice coping
  • strategies in real life scenarios- Exposure to stimuli and
  • triggers to dependency
  • Cognitive Processing Therapy-Re-framing cycles of misuse
  • EMDR (Eye Movement Desensitization and Reprocessing)
  • Brainspotting
  • Narrative Therapy- Provides contextual framework
  • Art Therapy and Expressive Techniques- Symbolic
  • representations- Increase insight and regain control
slide43

Expressive Treatments- Art Therapy

“Oftentimes, in trauma, healing cannot be fully completed because traumatic experiences become locked in various areas of the brain. We can’t work trauma through just by talking about it. Talking is primarily

a left hemisphere activity.

In order to complete the healing process, a person must access the limbic system and the right hemisphere,

where images, body sensations and feelings are stored.

By accessing them, a person is then able to

attach meaning to them and move this traumatic

material to a more adaptive resolution.”

~Belleruth Naparstek,

Invisible Heroes: Survivors of Trauma and How They Heal, 2005

slide44

Integrative Methods: Venn Diagram-

Past, Present, Futures Selves

slide45

Exprssing the Conflict-

Mixed Emotions in Recovery

Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

slide46

Case Example

“Heroin Kept Me Alive”

Ben’s Story

slide47

Integrated Trauma/Substance Abuse Treatment Model

  • For individuals with histories of trauma, any addictive behavior begins as a posttraumatic survival strategy aimed at regulating autonomic arousal and decreasing the traumatic memory.
  • The dependency results from the fact that the substances and behaviors require continued increases in dosage to maintain their effectiveness: eventually, use becomes misuse, and misuse becomes dependency.
  • Treatment MUST address the relationship between the trauma and the addictive behavior: the role of the addictive behavior in “medicating” traumatic activation, the origins of both in the traumatic past, and the reality that recovering from either requires recovering from both

Fisher, 2007

Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

slide48

“There is no problem that drugs and alcohol can’t make WORSE”

  • The substance use is intended to increase functioning, but eventually it becomes even more disruptive to the individual’s functioning than the initial symptoms that individual was self-medicating
  • May contribute to:
    • Relational Problems
    • Legal Issues
    • Financial Struggles
    • Health Problems (including increased mental health issues, suicide)

Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

slide49

Co-occurring Disorders, Co-occurring Treatment

  • Best to treat trauma and substance misuse at the same time, rather than previous schools of thought that suggested one should complete substance abuse treatment entirely before addressing trauma symptoms
  • Not separate problems but enmeshed, contribute to
  • one another in a complex, meaningful way
  • Trauma symptoms will exacerbate in sobriety
  • Need to predict and anticipate triggers and new
  • coping strategies
  • In certain cases, it may be too dangerous to attempt
  • complete sobriety right away and could potentially
  • jeopardize recovery
    • Schiraldi, 2009

Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

slide50

How do we do this?

  • Create a trauma-informed (safe, respectful, mindful, compassionate) space for the therapeutic work
  • Meet the client where he/she is

Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

slide51

Meet The Client Where

He or She Is

  • This is the essence of therapeutic work and is important with all populations
  • Service Members, in particular, are used to following the agendas of their chain of commands and Military Treatment Facilities
  • In many cases, SMs see treatment as a punishment of their bad behavior with substances, rather than as an opportunity to be heard, acknowledged, understood, supported
  • If we tell them what their diagnosis is or that we know what is best for them, we lose trust, we lose the relationship
  • It is most important to hear the SM and to meet them where they’re at, if they are in denial, they are the only ones who can bring themselves out of it
  • We can offer our knowledge, and help them explore the consequences of their SA, but in the end they are making the choices, and we are much more effective when the SM feels that we are “on their side”
  • “Relapse is Part of Recovery” – it is a learning opportunity
slide52

Psychoeducation is key

  • Shame is TOXIC – feelings of guilt and self-disgust lead to relapse, lack of confidence, decreased feelings of self-efficacy, hopelessness, isolation, depression, etc.
  • Psychoeducation about the relationship of trauma and substance abuse normalizes, instills hope, and increases feelings of self-efficacy
  • While one is still responsible for things that they have done while intoxicated, it does not mean these things are a reflection of their true self or who they are from this point forward
  • Hope is gained when an individual believes that they can be defined by their RECOVERY, rather than by their struggles with substance abuse
slide53

Appreciate Ambivalence

  • Encourage curiosity – allow the individual to genuinely explore and share the both the benefits and negative consequences of their substance use
  • Validate that choices made have been to help the individual feel safe, in control, etc.
  • Emphasize that sobriety is a necessity for safety and self-care but avoid black and white or “All Bad” thinking – it does not help an individual develop insight and can be a set up for failure
  • Don’t just acknowledge the ambivalence, appreciate it – it’s honest and it’s real, congratulate the individual on their braveness
  • EXERCISE – Dear John Letter

Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

slide54

Integrating 12 Steps

  • Offer Alcoholics Anonymous literature and Intergroup information
  • Involve 12 step principles – available worksheets on the 12 Steps, Big Book study
  • Don’t underestimate the power of “One Alcoholic Talking to Another”
  • Solely subscribing to philosophies such as those of AA may alienate the service member
  • Offer approaches but meet the client where he or she is

Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

slide55

Facilitating Mindfulness

Therapists needs to become more mindful. Refrain from interpretation and focus on observation. Help the individual focus on thoughts, feelings, and body sensations.

Mindful attention is present moment attention.

“When you are talking about what happened then, what do you notice happening inside you now?”

Fisher, 2007

slide56

Questions?

Thank you

Michael Defalco, Psy.D. Aynisa Leonardo, LCAT, AT-R, BC

The Military Wellness and Family Reintegration Programs

Holliswood Hopsitaland Hope for the Warriors www.militarywellness.com

MDefalco1@libertymgt.comaleonardo@libertymgt.com