Archival data was used by patients treated in the local VA, by the PTSD Clinical Team (PCT). These researchers used the PTSD Checklist – Military Version (PCL-M) and the Beck Depression Inventory-II (BDI-II-II). Both of these tests were administered frequently to keep track of the subject’s symp- toms, adding to the strength of the study (Tuerk, et. al, 2011). PE is arguably the most intense therapy, proven to get to the root of the trauma. The therapist must approach cautiously and be sure a strong rapport is established before treatment begins. The patient must be willing to face their biggest fears. One thing about PTSD is that the client doesn’t always re- member every aspect of what happened: there are often chunks of time missing, which can be frightening and add to the feel- ing that the trauma was “no big deal,” as some patients believe they have overreacted (Joseph, 2011). One of the reasons PE is shown to work so well on patients is that it can dig deep into the memory and pull out the missing pieces. For example, it can help the patient realize something as simple as whether or not a certain person was in the vicinity when the trauma occurred. Offering the patient this clarity helps them to feel more at peace about what happened, as there is less “unknown” attached to the trauma.
Consistent with what has been demonstrated in other intensive PTSD programs [16, 17] as well as traditional outpatient treatment , many patients were still symptomatic and did not reach remission at treat- ment endpoint. These findings may be indicative of sev- eral things. First, it is possible that these results are affected by our measurement approach in conjunction with an intensive delivery format. PTSD symptoms are typically assessed over the past month; at treatment end- point, this would include the time period before the vet- eran even started treatment. We attempted to correct for this by assessing past week PTSD symptoms and the effect sizes for past week symptoms were notably higher. How- ever, even a past week assessment would mean that vet- erans would have to account for symptoms occurring before one-third of the treatment was delivered. It is pos- sible that veterans will continue to experience symptom reduction following the IOP treatment without further intervention as they apply newly acquired skills in their home environment and become more confident in their treatment gains. Our findings may also suggest that for many patients, IOP programs can help to stimulate initial symptom reduction, but further outpatient treatment may be needed to achieve remission. Finally, it is also possible that these findings suggest that there may be ways of opti- mizing our treatment approach to improve outcomes even further, particularly for veterans with MST as their index
Untreated PTSD in opioid dependent individuals receiving opioid dependence therapies (methadone or buprenorphine maintenance, detoxification treatment, and drug-free residential treatment) has been associated with ongoing mental, physical, and occupational disability, despite improvements in substance abuse (Mills et al., 2007). Symptoms of PTSD do not improve with opioid therapy in those with co-occurring PTSD and opioid dependence (Trafton et al., 2006). Therefore, it is important to screen those presenting for treatment with opioid dependence for co-occurring PTSD. Like wise, it is important to screen those with trauma symptoms for concurrent opioid abuse. It is essential to develop a treatment plan that will appropriately address both disorders.
Jakupcak, M., Hoerster, K. D., Blais, R. K., Malte, C. A., Hunt, S., & Seal, K. (2013). Readiness for change predicts VA mental healthcare utilization among Iraq and Afghanistan war veterans. Journal of Traumatic Stress, 26, 165-168. doi:10.1002/jts.21768 Many veterans present to Veteran Affairs (VA) care intending to seek mental health treatment for symptoms of posttraumatic stress disorder (PTSD), depression, and/or alcohol misuse, yet most subsequently underutilize mental health care. This study examined the association of readiness for change with outpatient VA mental health care utilization in 104 treatment-seeking Iraq and Afghanistan war veterans who screened positive for PTSD, depression, and/or alcohol misuse at intake. Multivariate analyses demonstrated that readiness for change assessed at intake was positively associated (Incident Rate Ratio [IRR] = 1.22) with prospective outpatient mental health care utilization with demographic factors, military characteristics, and mental health burden in the model. Results suggest that interventions that target readiness to change, such as motivational interviewing, may improve treatment utilization in veterans presenting for mental health care. Kehle-Forbes, S. M., Meis, L. A., Spoont, M. R., & Polusny, M. A. (2016). Treatment initiation and dropout from prolonged exposure and cognitive processing therapy in a VA outpatient clinic. Psychological Trauma: Theory, Research, Practice, and Policy, 8, 107-114. doi:10.1037/tra0000065 Emerging data suggest that few veterans are initiating prolonged exposure (PE) and cognitive processing therapy (CPT) and dropout levels are high among those who do start the therapies. The goal of this study was to use a large sample of veterans seen in routine clinical care to 1) report the percent of eligible and referred veterans who (a) initiated PE/CPT, (b) dropped out of PE/CPT, (c) were early PE/CPT dropouts, 2) examine predictors of PE/CPT initiation, and 3) examine predictors of early and late PE/CPT dropout. We extracted data from the medical records of 427 veterans who were offered PE/CPT following an intake at a Veterans Health Administration (VHA) PTSD Clinical Team. Eighty-two percent (n = 351) of veterans initiated treatment by attending Session 1 of PE/CPT; among those veterans, 38.5% (n = 135) dropped out of treatment. About one quarter of veterans who dropped out were categorized as early dropouts (dropout before Session 3). No significant predictors of initiation were identified. Age was a significant predictor of treatment dropout; younger veterans were more likely to drop out of treatment than older veterans. Therapy type was also a significant predictor of dropout; veterans receiving PE were more likely to drop out late than
The Pandora’s Box hypothesis is sustained by a number of beliefs. The first is that most PTSD- SA individuals initially seek treatment for substance dependence. Advocates state that it would be inappropriate to then treat the clients for a problem for which they did not seek treatment. Secondly, substance abuse is associated with a decreased tolerance for negative affect. It is believed that addressing trauma-associated material early in treatment will increase their level of negative affect (Triffleman, Carroll, Kellogg, 1999). Third, many proponents of exposure therapy for PTSD state that this type of treatment requires the ability to cope with powerful affective and cognitive material. They believe that substance users do not meet these requisite criteria (Brady, Dansky, Back, Foa, & Carroll, 2001). Fourth, anecdotal evidence is presented that suggests PTSD or combined PTSD-SA treatment will be ineffective unless abstinence is first achieved. Last, clinical lore suggests that PTSD symptoms will reduce or remit with the cessation of substance use (Triffleman et al., 1999).
study and the overall symptom-focused outcomes of the treatment program have been reported elsewhere . Nonetheless, the relatively small clinical magnitude of improvement in PTSD symptoms is noteworthy and may be reflective of the complexity of clients who attended the program in that most had previously not benefitted from treatment in other services. Alterna- tively, it may indicate that subset of participants did not receive a full course of exposure-based therapy in their individual sessions. Unfortunately, we lack the data to determine if this was the case. We relied on a single measure of personal wellbeing, albeit one that has been validated in the Australian community and has sound psychometric properties. It may be that measures of Quality of Life across multiple life domains would detect improvements related to more specific areas of daily liv- ing. We were also not able to quantify the extent to which the residential treatment program targeted per- ceptions of personal wellbeing as opposed to PTSD symptoms. The relatively high rate of program partici- pants supported by funding (workers compensation schemes, Department of Veterans ’ Affairs and Depart- ment of Defence) and the high rate of follow-up attrition (64% of the sample attending the 9-month follow-up) suggests that the findings may not generalize to other studies and settings, although we believe it is reflective of the routine setting in which the study was conducted. Finally, our study did not include a control group or randomized allocation to treatment and control condi- tions precluding causal inferences about the role of treatment in changes in personal wellbeing.
Ginzberg et al.’s (2009) study suggests that a change in shame over the course of treatment mediates change in PTSD symptoms, as multiple linear regression analysis revealed that both the main effect and the interaction of shame slope by treatment condition were significant (β = 0.53, F(3,165) = 11.25; p <0.001). The authors suggest that about a third of the decrease in PTSD is due to the mediation effect of change in shame. They also found that the effect of treatment on shame and PTSD attenuates over time suggesting that if shame increased over time it did not necessarily increase PTSD symptoms, whereas in the waiting-list group if shame increased for a given participant, PTSD symptoms generally increased. However although this study establishes that there is a relationship, the finding is limited as it does not ascertain the cause. It is not possible to say whether the changes in shame caused the reduction of PTSD symptoms.
This article reviews available research data supporting the use of psychotherapy in the treatment of PTSD. Several interventions are discussed including: critical incident stress debriefing, psycho-education, exposure therapy, EMDR, stress inoculation therapy, trauma management therapy, cognitive therapy, psychodynamic therapy, hypnotherapy, image rehearsal, memory structure intervention, interpersonal psychotherapy, and dialectical behaviour therapy (DBT). They conclude that most methodologically robust studies indicate that psychotherapy helps to relieve symptom severity; but caution that there is no consistent information about whether these interventions are helpful in improving other domains of impairment and associated disability, even though these problems are often the greatest concern to patients. Furthermore, the authors conclude that the available evidence does not indicate when, and for whom, various
This study focuses on dropout in the treatment of patients with PTSD. PTSD is a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic experience, such as a natural disaster, serious accident, war, rape or other violence. The Diagnostic and Statistical Manual of Mental Disorders (5 th ed.; DSM-5; American Psychiatric Association, 2013) mentions a number of criteria for the diagnosis of PTSD. Patients with PTSD suffer from intrusive symptoms (e.g. nightmares, flashbacks, or recurrent and painful memories of the event), avoidance of trauma-related stimuli after the trauma (e.g. trauma- related thoughts, feelings, or external stimuli), negative alterations in cognition and mood (e.g. negative affect, feeling isolated, or feelings of guilt), and alterations in arousal and reactivity (e.g. irritability, hypervigilance, heightened startle reaction, difficulty concentrating, or difficulty sleeping). Between 2004 and 2005, the lifetime prevalence of PTSD in the Dutch adult population was approximately 7,4% (de Vries & Olff, 2009). Since 2009, the number of people registered with PTSD in general practice increased strongly by 380% in men and 277% in women (Hakstege & Klaassens, n.d.). This strong increase could be explained by the fact that people may seek professional help more quickly, or because PTSD is better recognized in mental health care, or PTSD is more accurately registered by general practitioners (Weehuizen, 2008). In 2013, 90.660 patients were treated for PTSD in the Netherlands (Hakstege & Klaassens, n.d.).
Concurrent Treatment of PTSD and Cocaine Dependence. Concurrent Treatment of PTSD and Cocaine Dependence (CTPCD), developed by Brady and Dansky (Back, Dansky, Carroll, Foa, & Brady, 2001; Brady, Dansky, Back, Foa, & Carroll, 2001), combines Coping Skills Training (CST), a cognitive- behavioral therapy for treating substance dependence (Carroll, 1998; Kadden et al., 1994; Monti, Abrams, Kadden, & Cooney, 1989) with exposure therapy for PTSD (Foa & Rothbaum, 1998). The treatment consists of 16, 90-minute sessions that occur twice a week on an individual basis. The substance use treatment consists of teaching coping skills, relapse prevention skills, and cognitive restructuring to help clients achieve abstinence from cocaine. During the first five sessions of treatment, substance use is the focus of therapy. Beginning with session six, however, exposure therapy begins and is presented during the first 45 minutes of each session. SUD treatment is provided during the second 45 minutes of the 90- minute session so that if substance craving increases in response to the exposure-elicited distress, SUD coping skills can be employed to reduce the craving response. In addition to the substance use and exposure treatment components, clients also learn relaxation skills (i.e., diaphragmatic breathing) and receive a general psychoeducational component that teaches clients the connection between their PTSD symptoms and substance use.
Another virtual reality machine includes an arousal control feature (VRET-AC). It runs on three computers: one displays the visual aspect of treatment; one displays the control panel and menu, and the third runs physiological monitoring (heart rate, skin temperature, etc.) (Wood, et al., 2010). The goal of VRET-AC is to help the warrior control reliving traumatic thoughts. Wood et al. (2010) studied VRET-AC as an effective treatment for combat-related PTSD and found the method effective for learning and creating new memories. The study involved over 350 VRET sessions over the course of three months with 30 service members. Wood et al. (2010) concluded that the VRET-AC group was able to desensitize because they became fully aroused during exposure and remained “on task”, which cannot occur during imaginal exposure.
Next, we conducted a RCT in which women (N = 74) diagnosed with PTSD after CA plus at least one of the following additional diagnoses/symptoms: at least 4 DSM-IV criteria of BPD, current major depressive dis- order, eating disorder, or alcohol and drug abuse were randomised to either the 12-week residential DBT-PTSD programme or a treatment-as-usual waiting list (TAU-WL) . The two primary outcomes were scores on the Clinician-Administered PTSD Scale (CAPS; ) and on the PDS . All measurements were done by blind raters. Only 6% of the DBT-PTSD group (2 out of 36) discontinued the treatment prema- turely. Hierarchical linear models yielded statistically sig- nificant group*time effects, indicating a more pronounced improvement in the DBT-PTSD group compared to the TAU-WL, with large effect sizes. Between-group effect sizes were large for the CAPS (Hedges’s g = 1.57), PDS (g = 1.27), Global Assessment of Functioning (GAF, ; g = 1.31), and Beck Depression Inventory-II (BDI-II, ; g = 1.13). No patient in the DBT-PTSD group showed worsening of posttraumatic symptoms or exaggerated dysfunctional behaviour [67, 71]. Neither BPD symptom severity, the number of BPD criteria, nor self-harm behaviour had a significant influ- ence on treatment outcome. Our findings provided clear evidence for the efficacy, high tolerability, and safety of the newly developed DBT-PTSD under residential conditions.
It is important that women serving in the military and our female veterans be provided care based on evidence (Resnick, Mallampalli, & Carter, 2012). The total incident PTSD cases newly diagnosed between 2000 to January, 2014 among Operation Iraqi Freedom, Operation New Dawn, and Operation Enduring Freedom deployed troops numbered 118,829 (Fischer, 2014), but these numbers are not broken out by gender. The incidence of PTSD in women after traumatic events is reported in the literature to be higher than in men (Olff, 2012), however we currently have no corroborating or refuting evidence in a combat situation. We do have evidence of epigenetic changes as important in gender differences in PTSD. Rachel Yehuda and Linda Bierer (2009) discuss the relevance of epigenetic findings and their implications for the diagnostic definitions for PTSD. They emphasize the importance of trauma exposure as an etiologic factor, and the utility that epigenetic methods may provide to the future of PTSD diagnosis and treatment (Yehuda & Bierer, 2009).
Most providers report a range of mental health services for veterans, and many are delivered as part of a wider package of interventions across the NHS and third sector. Various models of care are employed to deliver services for veterans. Collaborative working across sectors is commonplace. Peer support and ‘ Veterans Champions ’ are also in place. Referrals to services occur via many different routes and access via self-referral is available as an option in most cases. Multiple (clinical and non-clinical) professions are involved in the delivery of services and these services are available to veterans beyond the clinical setting. Several organisations mention specific support for veterans with PTSD. This does not necessarily mean that other providers do not provide targeted services for PTSD; rather, it appears that specialist treatment for this condition can be embedded in wider mental health services and assistance for comorbid conditions. Factors affecting the successful implementation of services and treatments for veterans with PTSD appear to be (1) inadequate funding and resources, (2) wider system challenges, (3) lack of research and development and (4) the inherent complexities of the target population. Evaluation of services and treatments appears to be taking place, but sporadically and to varying degrees. Responses were not received on all questions from every provider; therefore, the information set out below reflects where detail was offered to us. The findings are presented grouped by geographical area, reflecting the NHS England document. 17
For those who are unwilling to commit to an intensive ‘‘substance abuse’’ treatment program upon entering the system, we must find other ways to engage them in services while continuing to assess the impact of their substance use and, if applicable, building motivation for treatment targeting their substance use. We need to offer alternative treatments for OEF/OIF Veterans who are not ready to embrace traditional abstinence- based treatment. Although they are not motivated to quit drinking or using street drugs entirely, they may be motivated to make some changes to reduce the negative consequences of their substance abuse. For example, they may be willing to give up their use of drugs while continuing to drink or to cut back on their drinking. To better accommodate the needs of these Veterans, mental health and substance abuse treatment providers should consider a harm reduction approach advocated by Marlatt and colleagues (Marlatt, 2001; Marlatt & Witkiewitz, 2003). For Veterans who are at the precontemplation or contemplation stages identified by Prochaska and DiClemente (1984) regarding their drinking and/or drug use, a motivational interviewing approach described by Miller and Rollnick (2002) is recom- mended. We can greatly decrease dropout rates by offering Veterans who are ambivalent about change a motivational enhancement group or individual therapy with a professional trained in motivational interviewing. Najavits et al. (2009) have made several accommodations to their finding that men are more difficult to engage in groups initially than women. They offer men an opportunity to sit in on a few sessions of Seeking Safety, after which they can decide if they want to join. Another strategy they have adopted is to conduct an orientation group in a lecture format covering a few key topics, following which participants are invited to join a Seeking Safety group. They do not insist that men commit up front to a specific number of sessions and call treatment ‘‘training’’ to help overcome resistance to the idea of treatment. In addition to these measures, OEF/OIF Veterans may be more likely to participate in groups where age peers are well represented (Owen, 2008).
The aim of this study was to study the relationships between coping strategies and the severity of PTSD. Subjects were 50 treatment seeking Iranian veterans who had experienced war trauma at least once during their military services. Two instruments were used, including: Ways of Coping Questionnaire (Lazarus and Folkman, 1985) and Structured Interview for PTSD (SIP). Correlation coefficients were computed between various coping strategies and the PTSD severity scores. Results indicated that seeking social support, positive reappraisal, planful-problem solving, and self-controlling strategies were negatively correlated to PTSD severity. Escape-avoidance, distancing, accepting responsibility and confronting coping were positively correlated to the severity of PTSD. Theoretical discussion and the applications of these results are represented.