Ones: An Evolving Suite of Services in

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Ann Boyd
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Clinical Research Psychologist Office of Mental Health Services VA

1 Meeting the Complex Needs of Veterans with ihptsd and their Loved Ones: An Evolving Suite of Services in the VA Shirley M. Glynn, Ph.D. Clinical Research Psychologist Office of Mental Health Services VA Greater Los Angeles Health care System at West LA Research Psychologist, UCLA

2 No conflict of interest disclosures

3 Topics to be covered Combat PTSD prevalence Identification of PTSD symptoms that impact on families Research on the impact of PTSD on families The VA continuum of family services and relevance to PTSD How VA clinicians can help families dealing with PTSD New Descriptive and Intervention Research on OIF/OEF/OND Veterans dealing with PTSD Recent VA initiatives to meet the needs of Veterans and their loved ones dealing with PTSD Website Resources

4 Rule Number 2 by Heidi Kraft, Ph.D. Memoir of Dr. Kraft s service as a Navy Psychologist In Iraq Writes evocatively of choosing to distance herself from her family, especially her infant twins, so she can function in the war zone, and of the difficulty in reconnecting when she came home

5 PTSD Symptoms are common in Combat Veterans, though point prevalence estimate ranges differ 1 1. Vietnam (5-15%) 2. Persian Gulf (2-10%) 3. OIF/OEF/OND / veterans ( %) High rates of co-occurringoccurring disorders (SUD, Depression) 1 Richardson et al, 2010

6 Specific PTSD Symptoms Appear to Have Uniquely Deleterious Effects in Family Relationships On the next slides, the red items are particularly likely to be associated with family stress

7 Criterion B: intrusive recollection 1. Recurrent and intrusive distressing recollections of the event 2. Recurrent distressing dreams of the event 3. Acting or feeling as if the traumatic event were 4. Intense psychological distress at exposure to internal or external cues 5. Physiologic reactivity upon exposure to internal or external cues

8 Criterion C: avoidant/numbing 1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma 2. Efforts to avoid activities, places, or people that arouserecollections recollections of the trauma 3. Inability to recall an important aspect of the trauma 4. Markedly diminished interest or participation in significant activities

9 Criterion C: avoidant/numbing 5. Feeling of detachment or estrangement from others 6. Restricted range of affect (e.g., unable to have loving feelings) 7. Sense of foreshortened future re(e.g., does not expect to have a career, marriage, children, or a normal life span)

10 Criterion D: hyper arousal 1. Difficulty falling or staying asleep 2. Irritability or outbursts of anger 3. Difficulty concentrating 4. Hyper vigilance 5. Exaggerated startle response

11 What is the interplay of PTSD and perceived social support? Lui, Glynn, & Shetty (2009) one year longitudinal study of oral-facial injury survivors most from community violence 287 participants inner-cityinner city, ethnically diverse, lower SES Approximately 22% met dx criteria for PTSD at 12 months PTSD and Perceived Social Support (PSS) measured at one month, 6 months, and 12 months after the trauma Crossed-lagged modeling

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13 Robust literature suggesting that family problems are greater in Vietnam Combat Veterans dxed with PTSD than those without ih PTSD (Kulka et al, 1992: Jordan et al, 1992; Carroll et al, 1985; Mangino Mire et al, 2007; Beckham et al, 1997) More marital dysfunction/divorce More parenting problems and child difficulties More interpersonal violence in relationships Higher rates of distress in partners

14 Emerging literature documenting the association of PTSD and other mental health problems on family stress in OIF/OEF/OND veterans Higher rates of PTSD symptoms correlated with less intimate partner satisfaction (Nelson et al, 2007) and poorer interpersonal functioning (Shea et al, 2010) Greater distress in partners of Veteran dxed with PTS compared to those not dxed (Renshaw et al, 2008) Cumulative length of deployment predicts child depression and externalizing behavior (Lester et al, 2010)

15 How is the VA helping Veterans with PTSD and their loved ones?

16 VA Family Services Goals To assure that the need for services to families is discussed with all Veterans at least yearly & at the time of inpatient discharge To assure that identified family service needs are incorporated into treatment plans To assure that every medical center provides a continuum of recovery oriented services to Veterans and their families in order to meet the objectives specified in the treatment plan

17 Continuum of Family Services A graduated continuum of services is necessary to meet these varied needs. The full continuum ranges from: Family education / training brief problem focused consultations more intensive family psychoeducation and marriage and family counseling

18 Family Education/Training Family Education: A set of techniques that provide families with the information necessary to partner with the treatment team and support Veterans recovery Topics include: Symptoms, Prognosis, Treatments, Identifying & managing sources of stress and factors associated with good outcomes May be offered via written & video materials, one day workshops, and/or regularly scheduled meetings conducted by professionals (e.g., the SAFE program or the NAMI Family to Family program.) Veterans may or may not be present

19 Family Consultation Veteran Centered BriefFamilyConsultation (VCBFC) Family meets with mental health professional as needed to resolve specific issues related to the Veteran s treatment and recovery Intervention is brief; typically 1 5 sessions for each consultation Provided on as needed or intermittent basis If more intensive ongoing effort is required, family can be referred to Family/Couple Therapy

20 Family Psychoeducation (FPE) FPE: A collection of manualized interventions to equip families with the coping skills & attitudes that have been shown to reduce relapse and/or improve functional outcomes As of yet, data are limited in family EBPs for PTSD; no OMHS dissemination plan 20

21 Marriage and Family Counseling Integrative Behavioral Couples Therapy (IBCT; Jacobson and Christensen) Integrates goals of acceptance & change with behavioral treatment strategies Overarching goals are to reduce couples distress and strengthen family relationships Also include training in basic parenting skills and assessment of domestic violence National VA dissemination i i project underway About half of the couples seen by trainees during consultation ti include at least one Vt Veteran dxed dwith PTSD

22 Complexities of Seeing Families Dealing with ihptsd at VA Facilities i Couples treatment as part of Veteran s tx plan the Veteran is the formal client, not the couple, which makes it different from other conceptualizations of couples work Partners may need support and/or mental health treatment need to be familiar with local resources for referrals consider obtaining consent to talk with other providers referrals to SAFE, support groups, etc

23 Complicating Issues in Seeing Couples and Families in VA Medical lcenters (cont.) Staff expertise Issues skill development is important Veteran likely l to have physical and mental health comorbidities may be in other treatments Each clinician must keep contact with other providers Consider sequencing of treatment; want to avoid overwhelming Veteran with treatment demands 23

24 What Steps Can VA Clinicians Do to Help Veterans and Their Loved Ones?

25 Steps VA Clinicians Can Take to Help Veterans with PTSD and their Loved Ones Assess relationships with key supporters in Veteran s lives on an ongoing basis With Veteran consent, educate relatives so they can support participation in individual tx EBPs for PTSD and comorbidities Become proficient in the components of the continuum of family services offered in VA Learn about community resources available for family members to be prepared when they need referrals

26 Emerging PTSD Family Research Descriptive Studies Erbes, Polusny et al Minneapolis VA longitudinal study of National Guard Cohort includes evaluation of family issues Fischer, Sherman et al VISN 16 Qualtitative study on familyadjustmentadjustment of OIF/OEF/OND Veterans Millennium Cohort Study Following DoD cohort of 150,000, 000 including a subset of partners, for 21 years

27 Emerging Research Intervention Studies Monson et al. National Center for PTSD and Ryerson University completed RCT testing cognitive behavioral couples therapy for Sautter, Glynn et al New Orleans VA and UCLA ongoing RCT testing structured approach therapy for OIF/OEF veterans Perlick, Straits Troster t Bronx and Durham VA completed trial of multifamily group for OEF/OIF/OND Veterans with PTSD and TBI and their partners

28 Emerging Research Intervention Studies Dixon, Batten, Weissman VISN 5 trial of couples EFT for PTSD

29 Newer VA Family Initiatives that May Help Veterans and Their Loved Ones Deal with PTSD

30 Newer VA Family Initiatives that May Help Veterans with PTSD and Their Loved Ones Childcare pilot for Veterans receiving treatment at Northhampton, Pittsburgh, and Puget Sound VAMCs Coaching into Care telephone support for family members of Veterans to help them engage in VA care Supporting Family Resilience through joint DOD/VA strategic plan Problem Solving Initiative and FOCUS

31 Newer VA Family Initiatives Family Services Website on Sharepoint Caregiver support stipends Emotionally focused Couples Therapy VISN 5 training in December, 2012 Advanced Family Topics Monthly Call 4 th Monday of the month at noon EDT vants Roll out of Bh Behavioral lcouples Therapy for SUD September, 2012 Online parenting website for Veterans is being developed

32 Website Resources Family Services website MHS/familyservices/default.aspxaspx National Center for PTSD Maketheconnection.net Afterdeployment.org Mirecc.va.gov/coaching/

33 Web Resources for Parenting

34 Websites for Children s Issues Militarykidsconnect.orgorg Zerotothree.org military sections Sesameworkshop.org/tlc/ focusproject.org/focus world intro

35 We will continue discussing these issues during the lunch breakout, using a case example

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