T ha nk yo u fo r jo ining us T ha nk yo u to o ur spo nso rs, - - PowerPoint PPT Presentation
T ha nk yo u fo r jo ining us T ha nk yo u to o ur spo nso rs, APA Divisio n 19 (Milita ry Psyc ho lo g y) a nd Divisio n 18 (Psyc ho lo g ists in Pub lic He a lth, VA Se c tio n) T he re will b e a Q&A a t the e nd o f the
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ha nk yo u to o ur spo nso rs, APA Divisio n 19 (Milita ry Psyc ho lo g y) a nd Divisio n 18 (Psyc ho lo g ists in Pub lic He a lth, VA Se c tio n)
T
he re will b e a Q&A a t the e nd o f the we b ina r
Ple a se write q ue stio ns in the c ha t b o x We will try to mo nito r a s b e st we c a n
Rya n.He ss@ VA.g o v
T
RE
VI E W o f the pro b le m
RE
SUL T S o f o ur study
RE
COMME NDAT I ONS fo r T x
RE
SOURCE S fo r pro vide rs
23% o f I
ra q a nd Afg ha nista n ve te ra ns e xpe rie nc e PT SD sympto ms
(F ulto n e t a l., 2015)
De pre ssio n is the se c o nd mo st c o mmo n me nta l he a lth c o nditio n a mo ng OE
F / OI F / OND ve te ra ns
(E sio b u, 2015)
22% to 40% o f OE
F / OI F / OND ve te ra ns sc re e n po sitive fo r a lc o ho l misuse
(Ca lho un, E lte r, Jo ne s, K udle r, & Stra its-T ro ste r, 2008; Ha wkins, L a pha m, K ivla ha n, & Bra dle y, 2010)
De sc riptio n o f va ria b le s:
PT SD se ve rity (I V)
De pre ssio n se ve rity (I V)
Alc o ho l Use se ve rity (DV)
Re la tio nship Sa tisfa c tio n (Mo de ra to r)
Ag e , le ng th o f re la tio nship, disc ha rg e sta tus, se rvic e in the Army (Co va ria te s)
Pa rtic ipa nts: 594 wo me n, 303 me n
Hypo the se s:
1. F
SD sympto ms a nd De pre ssive sympto ms, tho se individua ls with hig he r le ve ls o f re la tio nship sa tisfa c tio n will e xpe rie nc e lo we r le ve ls o f a lc o ho l use .
2. F
SD sympto ms a nd De pre ssive sympto ms, tho se individua ls with lo we r le ve ls o f re la tio nship sa tisfa c tio n will e xpe rie nc e hig he r le ve ls o f a lc o ho l use .
3. F
SD a nd De pre ssio n, re la tio nship sa tisfa c tio n will mo de ra te a lc o ho l use .
T
PT
Ye t c o uple s the ra py is a n unde r-utilize d
I
nc luding the ro ma ntic pa rtne r ma y b e a wa y o f inc re a sing c ultura l se nsitivity
Ano the r pe rspe c tive is he a rd/ c o nside re d
Ma ny c ulture s a re c o lle c tivistic
F
fe e l unc o mfo rta b le
Milita ry c ulture is c e rta inly c o lle c tivistic
F
unit/squad/platoon is prioritized (“service before self” and “selfless service”)
Co uple s the ra py ma y b e a wa y to ta p into tha t
c o o pe ra tive / c o lla b o ra tive me nta lity o f the milita ry
Including a romantic partner may decrease the service member/veteran’s anxiety Ca n fo c us o n no n-thre a te ning issue s first
He lp-se e king Se tting a ppro pria te b o unda rie s Se lf-c a re Asse rtive c o mmunic a tio n Ho w to use time o uts Ac tive liste ning Stre ng ths-b a se d a ppro a c h (wha t is wo rking we ll in the re la tio nship)
I
nc luding a ro ma ntic pa rtne r o ffe rs the c linic ia n the
ability to view the patient’s interpersonal style in real time
I
nc luding a ro ma ntic pa rtne r o ffe rs the o ppo rtunity to pro vide psyc ho e duc a tio n
Ofte n, pa rtne rs kno w ve ry little a b o ut PT
SD, SUD, o r de pre ssio n
Ca n b e do ne b e fo re a tra uma -info rme d a ppro a c h
Ma y se rve to e nha nc e mo tiva tio n/ re a dine ss
Ca n b e utilize d to a ddre ss CC
CBT
F T , Be ha vio ra l Co uple s T he ra py fo r AUD, Co g nitive Be ha vio ra l Co njo int T he ra py fo r PT SD
Ca n b e use d a s a n a djunc t/ supple me nt to individua l T
x
Ca n b e pa rt o f a fte r-c a re
Afte r sta b iliza tio n/ sympto m de c re a se
De pre ssion PT SD SUD
Whe n o ne me mb e r o f a ro ma ntic re la tio nship is de pre sse d, the re c a n b e the te nde nc y fo r the o the r pa rtne r to b e c o me de pre sse d (ne g a tive fe e db a c k lo o p) A ha llma rk fe a ture o f PT SD is a vo ida nc e . T his a vo ida nc e c a n c e rta inly ma nife st in a nd c a use da ma g e to the ro ma ntic re la tio nship. SUD c a n b e a n a tte mpt to iso la te / numb / fo rg e t. Ofte n c o nc e ptua lize d a s a fo rm o f a vo ida nc e I t ha s b e e n sug g e ste d tha t de pre ssio n is a fo rm o f e xc e ssive se lf-fo c us (Rumina te
pe rc e ive d fa ilure s, e tc .) So me the o re tic a l o rie nta tio ns (e .g ., E F T ) e nc o ura g e a ppro a c h b e ha vio rs Almo st a ll tre a tme nts fo r SUD e mpha size the impo rta nc e o f so c ia l suppo rt (e .g ., AA/ NA, CBT
, Ce le b ra te Re c o ve ry, e tc .) Se e king this so c ia l suppo rt c a n b e g in with c o ming to the ro ma ntic pa rtne r ho ne stly a nd in a sta te o f vulne ra bility I t ha s b e e n re c o mme nde d tha t o ne re me dy fo r the e xc e ssive se lf-fo c us tha t c a n pe rpe tua te de pre ssio n is to ha ve the individual fo c us o n so me o ne e lse (e .g ., ro ma ntic pa rtne r) a nd le a rn to c ultiva te sympa thy/ e mpa thy L e a rning to a ppro a c h the ro ma ntic pa rtne r c a n b e use d a s sc a ffo lding to e nc o ura g e the se rvic e me mb e r/ ve te ra n to a ppro a c h o the r a vo ide d issue s. T his ma y se rve to a me lio ra te the PT SD. CBT
“Supportive Significant Other” which c an be a ro ma ntic pa rtne r a nd c a n b e
a nyo ne tha t c a re s fo r the ve te ra n a nd stre ng the ns the ir re c o ve ry
With the re c e nt inc re a se d utiliza tio n o f te le he a lth, it ma y
be easier to access the service member/veteran’s
ro ma ntic pa rtne r (le ss wo rk fo r the m to c o me in fo r the the ra py se ssio n)
T
his ma y b e a wa y fo r us to e xpa nd o ur c a re fo r o ur pa tie nts. I n c e rta in VA se tting s, ve te ra ns ha ve b e e n re fe rre d fo r c o uple s the ra py in the c o mmunity b e c a use the ir VA did no t o ffe r c o uple s the ra py o r the wa it fo r c a re wa s to o g re a t
Ce rta inly the re a re c o ntra indic a tio ns (e .g ., do me stic vio le nc e )
T
he re ma y b e time s whe n it is c linic a lly indic a te d to fo c us o n PT SD/ SUD/ de pre ssio n in a n individua l fo rma t
Ma ny pro vide rs a re wa ry o f do ing dya dic the ra py
May fear becoming “the couples therapist” Ma y fe e l unq ua lifie d
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nde e d, VA o ffe rs c o mpa ra tive ly fe w tra ining s fo r c o uple s the ra py
Co uple s Co a c h a pp (a va ila b le fo r Ma c a nd Andro id de vic e s)
Co uple s Co a c h wa s ma de b y the mo b ile me nta l he a lth te a m o f the Na tio na l Ce nte r fo r
PT SD, Disse mina tio n & T ra ining Divisio n
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F T we b ina r a va ila b le a t http:/ / va -e e rc -e e s.a do b e c o nne c t.c o m/ pd6wq s72p0p2/
VA E
F T listse rv
E
ma il Je rika .No ro na @ va .g o v
Ca re g ive r Suppo rt Pro g ra m (a va ila b le a t ma ny VA ho spita ls) Wa rrio r to So ul Ma te (W2SM) re tre a t VA-spo nso re d tra ining s fo r I
nte g ra tive Be ha vio ra l Co uple s T he ra py, CBT
Co g nitive Be ha vio ra l Co uple s T he ra py fo r PT SD
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a mily Se rvic e s Sha re Po int Site fo r VA c linic ia ns
https:/ / va ww.po rta l.va .g o v/ site s/ OMHS/ fa milyse rvic e s/ de fa ult.a spx
Study de sig ne d to a sse ss re la tio nship sa tisfa c tio n a nd func tio n Pa rtne re d me n a nd wo me n re c ruite d thro ug h so c ia l me dia Surve ys we re simila r b ut no t ide ntic a l a nd c o lle c te d a b o ut 18 mo nths a pa rt. Me a sure s we re c o mple te d o nline , a no nymo usly Study funde d b y Divisio n 19 – So c ie ty fo r Milita ry Psyc ho lo g y
De mo g ra phic I
nve nto ry
AUDI
T
Sc o re ra ng e 0-12
Wo me n: Sc o re s 3+ = po sitive sc re e n fo r pro b le ma tic use Me n: Sc o re s 4+ = po sitive sc re e n fo r pro b le ma tic use
Couples’ Satisfaction Index-4
Sc o re ra ng e : 0-21
Sc o re s < 13.5 = distre sse d re la tio nship
PT
SD Che c klist-5
Sc o re ra ng e : 0-80
Sc o re s >31 = pro b a b le PT
SD dia g no sis
Pa tie nt He a lth Que stio nna ire -9 (de pre ssio n)
Sc o re ra ng e : 0-27
Sc o re s >5 mild de pre ssio n o r wo rse
Me ns’ and wo me ns’ data analyzed separately Ana lyse s c o va rie d fo r re la tio nship dura tio n, ma rita l sta tus (pa rtne re d vs ma rrie d), a nd Army
se rvic e
2-pa rt hurdle mo de ls using re g re ssio n with inte ra c tio ns we re use d
Pa rt I
: No a lc o ho l use vs so me (b ina ry)
Pa rt I
I : Any a lc o ho l use a mo ng tho se who drink (line a r)
De pre ssio n a nd PT
SD a na lyze d se pa ra te ly
Po stho c a na lyse s e xa mine d a prio ri se le c te d PT
SD sympto m c luste rs fo und in Anhe do nia Mo de l
I
nte ra c tio n te rms e xa mine d re la tio nship sa tisfa c tio n a t the me a n a nd +/ - SD
Hurdle Wome n Me n
Hurdle Wome n Me n
Hurdle 1 – No vs So me Alc o ho l (b ina ry) PT SD PT SD De pre ssio n De pre ssio n Hurdle 2 – So me a lc o ho l use a mo ng tho se tha t drink (line a r) PT SD PT SD De pre ssio n De pre ssio n PT SD - NACM PT SD - NACM PT SD - Anhe do nia PT SD - Anhe do nia PT SD – Dyspho ric Aro usa l PT SD – Dyspho ric Aro usa l
PT SD
PT SD Bla is, Ge ise r, & Cruz, 2018
J o f Affe c tive Diso rde rs
Bla is, 2020 (unde r re vie w)
PT SD
Bla is, Ge ise r, & Cruz, 2018
J o f Affe c tive Diso rde rs
Bla is, 2020 (unde r re vie w)
Nondr inke rs (n = 116; 20% )
PCL
5 = 30.33
thre sho ld o f + sc re e n
PHQ9 = 11.34
Mo de ra te de pre ssio n
CSI
4 = 12.96
distre sse d
Drinke r s (n = 487; 80% )
PCL
5 = 24.00
- sc re e n
PHQ9 = 9.87
Mild-mo de ra te de pre ssio n
CSI
4 = 14.89
no ndistre sse d
AUDI
T C = 3.2
+ sc re e n
Nondr inke rs (n = 61; 20% )
PCL
5 = 23.19
- sc re e n
PHQ9 = 8.10
Mild de pre ssio n
CSI
4 = 13.42
distre sse d
Drinke rs (n = 242; 80% )
PCL
5 = 23.74
- sc re e n
PHQ9 = 9.76
Mild-mo de ra te de pre ssio n
CSI
4 = 13.26
distre sse d
AUDI
T C = 3.3
- sc re e n
Hurdle Wome n Me n
Hurdle 1 – No vs So me Alc o ho l (b ina ry) PT SD PT SD De pre ssio n De pre ssio n Hurdle 2 – So me a lc o ho l use a mo ng tho se tha t drink (line a r) PT SD PT SD De pre ssio n De pre ssio n PT SD - NACM PT SD - NACM PT SD - Anhe do nia PT SD - Anhe do nia PT SD – Dyspho ric Aro usa l PT SD – Dyspho ric Aro usa l
Wome n Me n
Hurdle 1 – No vs So me Alc o ho l (b ina ry) PT SD PT SD De pre ssio n De pre ssio n Hurdle 2 – So me a lc o ho l use a mo ng tho se tha t drink (line a r) PT SD PT SD De pre ssio n De pre ssio n PT SD - NACM PT SD - NACM PT SD - Anhe do nia PT SD - Anhe do nia PT SD – Dyspho ric Aro usa l PT SD – Dyspho ric Aro usa l
PT SD Se ve rity Alc o ho l Use Se ve rity Re la tio nship Sa tisfa c tio n
At lo w le ve ls o f re la tio nship sa tisfa c tio n, hig he r PT SD sympto ms a re a sso c ia te d with hig he r a lc o ho l use PT SD Se ve rity Alc o ho l Use Se ve rity Re la tio nship Sa tisfa c tio n
At lo w le ve ls o f re la tio nship sa tisfa c tio n, hig he r NACM sympto ms a re a sso c ia te d with hig he r a lc o ho l use Alc o ho l Use Se ve rity Re la tio nship Sa tisfa c tio n NACM Se ve rity
At lo w a nd me dium le ve ls o f re la tio nship sa tisfa c tio n, hig he r dyspho ric a ro usa l sympto ms a re a sso c ia te d with hig he r a lc o ho l use Alc o ho l Use Se ve rity Re la tio nship Sa tisfa c tio n Dyspho ric Aro usa l Se ve rity
At lo w a nd me dium le ve ls o f re la tio nship sa tisfa c tio n, hig he r de pre ssive sympto ms a re a sso c ia te d with hig he r a lc o ho l use
Alc o ho l Use Se ve rity Re la tio nship Sa tisfa c tio n De pre ssio n Se ve rity
Amo ng wo me n, re la tio nship sa tisfa c tio n is re la te d to the de pre ssive c o mpo ne nts o f PT
SD a nd de pre ssio n a nd a lc o ho l use
Pa rtic ula rly a t lo w a nd a ve ra g e le ve ls o f re la tio nship sa tisfa c tio n
Unde rsta nding why wo me n a re using a lc o ho l whe n e xpe rie nc ing hig he r de pre ssio n a nd lo we r
re la tio nship sa tisfa c tio n is ke y – a nd unde rstudie d
Muc h o f wha t we unde rsta nd a b o ut re la tio nship sa tisfa c tio n is usua lly sub sc rib e d to me n
ve te ra ns – we ne e d to kno w mo re a b o ut wo me ns’ experiences
Avo ida nc e sympto ms (Crite ria C) o f PT
SD
Avo ida nc e & Sub sta nc e Use Diso rde rs Avo ida nc e & Re la tio nship Sa tisfa c tio n
PT SD I ntrusio ns/ T rig g e rs Avo ida nc e (pe o ple , e mo tio ns, situa tio ns) Avo ida nt Be ha vio rs (a lc o ho l use , c o nflic t, dista nc e ) Re la tio nship E ffe c ts (la c k o f sha re d a c tivitie s, po sitive inte ra c tio ns) Po ssib le Re info rc ing Be ha vio rs fro m Pa rtne r
Hype ra ro usa l sympto ms (Crite ria E
)
Hype ra ro usa l & Sub sta nc e Use Diso rde rs Hype ra ro usa l & Re la tio nship Sa tisfa c tio n
PT SD I ntrusio ns/ T rig g e rs Hype ra ro usa l (a ng e r, irrita b ility, inso mnia ) Se lf-Me dic a ting Be ha vio r (sub sta nc e use ) Re la tio nship E ffe c ts (de fic its in c o mmunic a tio n ( c o nflic t ma na g e me nt) Po ssib le Re info rc ing Be ha vio rs fro m Pa rtne r
Ne g a tive Alte ra tio ns in Mo o d & Co g nitio n (Crite ria D)
Ne g a tive sympto ms & Sub sta nc e Use Diso rde rs Ne g a tive sympto ms & Re la tio nship Sa tisfa c tio n PT SD Intrusio ns/ T rig g e rs Ne g a tive Alte ra tio ns in Mo o d/ T ho ug hts (de pre ssio n, a nhe do nia ) Se lf-Me dic a ting & Numb ing (sub sta nc e use , dista nc ing ) Re la tio nship E ffe c ts (la c k o f sha re d a c tivitie s, po sitive inte ra c tio ns, sha re d e mo tio ns) Po ssib le Re info rc ing Be ha vio rs fro m Pa rtne r
E
vide nc e -Ba se d Psyc ho the ra pie s in the VA/ Do D & Co uple s/ F a mily T he ra py
VA/DoD CBG’s and recommendations for PTSD
L
ink to 2017 Guide line : VA/ Do D Clinic a l Pra c tic e Guide line s fo r PT SD
VA/DoD CBG’s and recommendations for SUD
L
ink to 2015 Guide line : VA/ Do D Clinic a l Pra c tic e Guide line s fo r SUD
Curre nt E
mpha sis o n Co nc urre nt T re a tme nt o f PT SD a nd Sub sta nc e Use Diso rde rs
I
nte g ra te d Mo de l ve rsus Se q ue ntia l Mo de l
➢ “Cognitive-Be ha vio ra l Co njo int T
he ra py fo r PT SD: Ha rne ssing the
Healing Power of Relationships” by Candice Monson & Ste ffa ny
F re dma n
➢ Curre nt Na tio na l T
ra ining pro g ra m a va ila b le in the VA syste m
➢ CBCT
fo r PT SD Sha re Po int
➢ F
ro m a stric t pro to c o l pe rspe c tive , it do e s a llo w fo r tre a tme nt o f
individuals with PTSD as well as “substance abuse” (individuals with more severe SUD are “generally not recommended”)
“Behavioral Couples Therapy for Alcoholism and Drug Abuse” by
Timothy J. O’Farrell and William F
a ls-Ste wa rt
Curre ntly no a c tive Na tio na l T
ra ining s in BCT fo r SUD in the VA
BCT
L
ist o f T ra ine d Pro vide rs in VA he re
Altho ug h no t dire c tly de ve lo pe d fo r PT
SD, e me rg ing e vide nc e tha t it ma y he lpful in a ddre ssing PT SD sympto ms in a dditio n to tre a ting SUD sympto ms
Co nside r inc o rpo ra ting re la tio nship sa tisfa c tio n a sse ssme nts o r
pro b ing fo r func tio na l a spe c t o f PT SD/ SUD sympto ms inte g ra te d into dya dic re la tio nship prio r to tre a tme nt se le c tio n
Po te ntia lly spe c ia l c o nside ra tio n fo r wo me n, individua ls with histo ry o f
se xua l tra uma (MST )
Po ssib le Re so urc e s
Within VA system, your facility’s Local Evidence-Ba se d Psyc ho the ra py
Co o rdina to rs (L E BPCs) c a n he lp fa c ilita te re fe rra ls fo r CBCT a nd BCT .
Also within VA system, your facility’s PTSD/SUD specialist can be a
re so urc e
Co uple s T
he ra py Appro a c he s b e yo nd the Clinic a l Pra c tic e Guide line s & VA E vide nc e -Ba se d Psyc ho the ra py Mo de l fo r PT SD a nd SUD
Good news…
Co uple the ra py is e ffe c tive
70% o f c o uple s re c e iving tre a tme nt b e ne fit I
n me ta -a na lyse s o f c o uple the ra py, tre a tme nt e ffe c ts a re simila r to individua l tre a tme nt (d = .60 - .80)
Couple therapy is effective for “individual” disorders
Po we rs e t a l. (2008) me ta -a na lysis o f b e ha vio ra l c o uple s the ra py fo r tre a ting
a lc o ho l-re la te d issue s
Couples’ interventions are well-e sta b lishe d fo r tre a ting de pre ssio n Couples’ interventions are effective at assisting partners coping in the face of
tra uma
I
nitia lly de ve lo pe d b y Susa n Jo hnso n & L e s Gre e nb e rg
Mo st re c e nt tre a tme nt ma nua l (Jo hnso n, 2020)
Dra ws upo n syste ms the o ry, a tta c hme nt sc ie nc e , a nd the po we r
ro le tha t a ffe c t pla ys in sha ping o ur se nse o f se lf a nd o the r.
Ro b ust line o f re se a rc h (d = .93; L
e e e t a l., 2020)
E
F T ha s b e e n studie d b e yo nd g e ne ra l re la tio na l distre ss to e xa mine
how “individual symptomology” is treated within a relational context
a nd fra me , inc luding ve te ra ns suffe ring fro m de pre ssio n a nd PT SD sympto ms (We issma n e t a l., 2017).
“Since affect dysregulation is the primary experience of those coping with the
e c ho e s o f b a ttle , pro viding tre a tme nt tha t c a n a ddre ss the e mo tio na l c lima te
within and between a service member and their partner makes sense…”
Sta g e 1: Cyc le De -E
sc a la tio n
Goal: The couple will gain a “meta” perspective of their negative
inte ra c tio na l pa tte rn. Co nc e rns re la te d to SUD, o r the the wa ys a ffe c t dysre g ula tio n ma nife sts itse lf a re pla c e d within the c o nte xt o f a re la tio na l fra me .
Partner Partner
Primary Emotion Primary Emotion Perceptions/Attributions Perceptions/Attributions Secondary Emotion Secondary Emotion Behavior Behavior Unmet Attachment Needs Unmet Attachment Needs
Sta g e 1: Cyc le De -E
sc a la tio n
Goal: The couple will gain a “meta” perspective of their negative
inte ra c tio na l pa tte rn. Co nc e rns re la te d to SUD, o r the the wa ys a ffe c t dysre g ula tio n ma nife sts itse lf a re pla c e d within the c o nte xt o f a re la tio na l fra me .
Sta g e 2: Re struc turing I
nte ra c tio n
Go a l: E
xpa nd a tta c hme nt-re la te d e mo tio ns a nd ne e ds
Go a l: Sha re the se ne e ds with the ir pa rtne r Go a l: Pro mo te a c c e pta nc e a nd suppo rt b e twe e n pa rtne rs
Sta g e 3: Co nso lida tio n a nd I
nte g ra tio n
Go a l: e sta b lish ne w pa tte rns tha t pro mo te ARE
– a c c e ssib ility, re spo nsive ne ss, a nd e ng a g e me nt
I
n a se c ure ly a tta c he d re la tio nship, pa rtne rs ha ve the po te ntia l to a c t a s pro te c tive fa c to rs a g a inst the c o mple x stre ss tha t c o me s with fro m the dutie s o ur se rvic e me mb e rs c a rry o ut.
Ba c k, S.D., F
.B., K ille e n, T .K ., Mills, K .L ., T e e sso n, M., Co tto n, B.D., Ca rro ll, K .M., & Bra dy, K .T . (2015). Co nc urre nt T re atme nt o f PT S D and S ubstanc e Use Diso rde rs Using Pro lo ng e d E xpo sure (COPE ): T he rapist Guide . Oxfo rd, UK : Oxfo rd Unive rsity Pre ss.
Ca lho un P.S., E lte r J.R., Jo ne s E .R. Jr, K udle rH., Stra its-T rö ste r K . (2008). Ha za rdo us a lc o ho l use a nd re c e ipt
ra q a nd Afg ha nista n. J Clin Psyc hiatry; 69(11):1686-1693. do i:10.4088/ jc p.v69n1103
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