Veterans and PTSD Toni L. Enemy Hunter Psychiatric Rehabilitation/REHA 425 Professor McDermott October 29, 2011 Abstract The United States is seeing an increasing number of Veterans coming back from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) being diagnosed with Post-Traumatic Stress Disorder (PTSD). PTSD is affecting the lives of men and women, their family and those closest to them. The goal of this paper is to give some general information for women and their families experiencing PTSD. It will give symptoms and treatment options available to women veterans.
Women Vets and PTSD According to the 2009 and 2010 National Survey on Drug Use and Health, Substance Abuse and Mental Health Services Administration (SAMHSA), nearly 600,000 veterans aged 18 or older experienced a co-occurring substance use disorder and mental illness in the past 12 months. Post-Traumatic Stress Disorder (PTSD) is now becoming more prevalent with men and women in the military. How can the families of the veteran better understand what to expect and how to deal with their loved ones suffering from PTSD? Definition
According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; APA, 2000) the diagnostic criteria for PTSD include a history of exposure to a traumatic event meeting two criteria and symptoms from each of three symptom clusters: intrusive recollections, avoidant/numbing symptoms, and hyper-arousal symptoms (Appendix 2). Challenges The British Medical Journal reported that veterans do not experience trauma or disabling symptoms until they return from the war (Gabriel & Neal, 2002).
Friedman said PTSD symptoms appear when they return home trying to readjust to civilian life. When a person is on active duty in the military, if one does not have a physical injury then psychological symptoms are seen as a weakness and being a coward (Friedman, 2004). Those that did seek help found it difficult to be diagnosed because they were not exposed to direct combat (i. e. hostile fire, returning fire, or seeing others injured). The veterans that do have PTSD from military trauma are from non-combative events such as sexual trauma.
They may feel alone and worry about their families. PTDS is comorbid with traumatic brain injuries and other psychiatric disorders such as depression, social phobia, panic disorder, substance abuse, and mood and anxiety disorders (Feczer, 2009). [W]e deny that war changes its participants forever- …America claims innocence and goodness as fundamental traits. We believe that our young men and women should be able to go to war, get the job done, and return home blameless and well. (Tick, 2005) Intervention
The Readjustment Counseling Service is available for veterans who served in war zones, Vietnam Era Veterans, veterans that experienced sexual trauma while in the military, and for family members that have lost loved ones while on duty. At a Veteran Center, the services that are provided are: individual counseling, group counseling, marital and family counseling, addiction counseling, benefits assistance and referral, employment referral and counseling, community education, liaison with VA facilities, referral to community agencies, contracts with area counselors and Mobile Vet Center Outreach.
The client first has to go through assessments to figure out the best therapeutic approach. They need to be screened for victimization, suicidal potential, addictive behaviors, differential diagnosis, comorbidity, and family assessment (Meichenbaum, 1995). Medications, along with therapy, have been the most helpful types of treatment for PTSD. The medications used are antidepressant medications, anti-anxiety medications, mood stabilizing medications, and other medications to ease nightmares, irritability, sleeplessness, depression, and anxiety (Feczer, 2009). It is important when interviewing the client to find out their childhood history.
Many times trauma during childhood will not come out until later in life and it can be the underlying issue to their problems (Feczer, 2009). Therapy Modalities PET After a traumatic event, many individuals experience distress and signs of PTSD. The veteran may experience suffering when dealing with the recollections related to the trauma. This type of therapy helps by approaching those thoughts, feelings, and events that the client has been avoiding because of the stress they cause. By repeated exposure to the emotions it helps the veteran reduce the power thoughts have over the client.
However, during the assessment, it is important to discuss with the veteran the main event(s) that causes the stress. By doing this at a comfortable pace, the exposure to that trauma can be dealt with accordingly (Creamer & Forbes, 2004). The first part of the therapy is education. The counselor will explain the treatment, the common trauma reactions and symptoms of PTSD. PET helps the veteran understand what the goals are for the treatment and what to expect for the duration of the upcoming sessions. Teaching methods of breathing techniques will help the veteran to relax.
Breathing changes when a person becomes anxious or fearful. This is a short-term technique to assist in managing sudden distress. The third aspect of PET is in vivo exposure where the client has exposure to real world situations or events that may be anxiety-producing. This is safely done by approaching the situation that has been avoided because of the stress it causes. PET uses imaginal exposure where the veteran talks through the trauma(s) with the counselor. By talking, it helps the client to gain control over the traumatic events and realize that he or she does not have to be afraid of his or her memories.
The overall goal is to work through the events from least to most traumatic events and what is comfortable for the client. This type of therapy is usually eight to fifteen sessions that last about ninety minutes (Resick, Nishith, Weaver, Astin,& Feuer, 2002). CPT Many times those with PTSD have problems dealing with their thoughts and memories of the trauma they have been though. They may get “stuck” in their thoughts and have a hard time making sense of what has happened or is happening to them. CPT helps in giving clients a new way of dealing with their thoughts and to gain an understanding of the events that haunt them.
There are four parts to CPT: learning about PTSD symptoms, becoming aware of thoughts and feelings, learning skills and understanding changes in beliefs. CPT requires educating the client about PTSD and what to expect from the disorder. The veterans can ask questions and find out how the skills are going to help them. In this modality, the client needs to become aware of their thoughts and feelings. When bad things happen we want to know why they happen. Clients can get stuck in their thought process and not be able to let it go.
However, with CPT a person learns to pay attention to these thoughts that the trauma has caused and discuss how they make one feel. Then he or she can take a step back and see how it affects the person now. This will hopefully help the veteran think of the trauma in a different way. This can be done by writing about it or talking to the counselor. Next, the veterans need to begin learning the skills to help challenge their thoughts and question them as well. This is done by doing worksheets (appendix 1). These worksheets will help veterans decide the way they want to think and feel about their traumatic situations.
These skills will eventually help in dealing with every day issues. Finally, there is trying to understand the changes in beliefs. There are common changes that happen after going through a trauma. There are going to be changes in the way a person thinks about safety, trust, control, self-esteem, other people and relationships. By talking about these beliefs, hopefully they can find a balance with the beliefs before and after the trauma. The approximate time for this type of therapy is twelve sessions. EMDR The final type of therapy is Eye Movement Desensitization and Reprocessing or EMDR.
Clients that are involved in EMDR use imaginal exposure of their trauma and at the same time the counselor uses their index finger for them to follow back and forth. EMDR therapy seems to directly affect the brain by unlocking the traumatic memories, allowing clients to resolve them. Veterans work through the upsetting memory, beliefs, feelings, sensations until they are able to think about the event without reliving it. The memory is still there, but not as upsetting. It is like detaching oneself and watching a movie but relieving the trauma at the same time (Barton, Smith, Corcoran, 2011).
Case Management, Employment and Vocational Rehabilitation According to the Vocational Rehabilitation and Employment Program that Congress prepared, case managers work closely with Vocational Rehabilitation Counselors (VRC) to create a rehabilitation plan. This plan consists of evaluation and planning for the future goals of the veteran. The veteran is evaluated to see if he or she is capable of independent living or will need rehabilitation services. The VRC is responsible to see that referrals for medical, eye care and dental are taken care of for the client.
The vocational-education counselor will be able to assist the veteran in acquiring education, training, equipment, and financial aid if the client needs to develop new skills for employment. The President of the United States is also giving great tax breaks to employees for hiring veterans. The Counselor and Support Systems The downfall to helping veterans with PTSD is that there are not many counselors have the experience with this type of client. Counselors in this field are few, especially in the rural and underserved geographic areas.
The VA resources are overwhelmed with clients so there is a backlog, which creates frustration with veterans. There are many that have contemplated or have committed suicide because they did not receive the help they needed. According to the National Center for PTSD, some may have had past mental health issues and may not have good support systems in addition to what was mentioned earlier. So that is why it is important to have a good support system and education is essential for the families when the veteran returns home. They will more than likely not be the same person as they were before they were deployed.
Conclusion Veterans do so much for the United States citizens and we need to be thankful for the job they do for our freedom. The veterans put their lives in danger so we can live the life as Americans. Veterans deserve the respect and assistance when they return home to us. So it is my opinion that we do our best to ensure they can become productive citizens once again. I would like to be part of that team to assist in helping veterans adjust back into civilian life. I would like to see more citizens do the same by helping the veterans any way possible.
Where would the United States be if we did not have such a great military team? References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed. ). Washington, DC: Author. Feczer, D. A. (2009). Forever changed: Posttraumatic Stress Disorder in female military veterans, A Case Report. Perspectives in Psychiatric Care. Friedman, M. (2004). Acknowledging the psychiatric cost of war. New England Journal of Medicine, pp 351, 75-77. Gabriel, R. A. (2002). Post-traumatic stress disorder or somatic dysfunction after military conflict may hide posttraumatic disorder.
British Medical Journal, pp 324, 340-342. Tick, E. (2005). War and the soul: Healing our nation’s veterans from post-traumatic stress disorder. Wheaton, IL: Quest Books. Masson, N. (2010). Mindful Cognitive Processing Worksheet. Retrieved from http://drnataliemasson. com/images/Mindful%20Cognitive%20Processing%20Worksheet. pdf Creamer, M. , Forbes D. (2004). Treatment of Posttraumatic Stress Disorder in Military and Veteran Populations, Psychotherapy: Theory, Research, Practice, Training, (Vol. 41, pp. 388-398). Resick, P. , Nishith, P. , Weaver, T. , Astin, M. , Feuer, C. 2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, (Vol. 70, pp. 867-879). Bartson, S. , Smith. , M. , Corcoran, C. (2011). Help Guide. EMDR Therapy. Retrieved from http://www. helpguide. org/mental/pdf/emdr. pdf Meichenbaum, D. (1995). A clinical handbook/practical therapist manual for assessing and treating adults with post-traumatic stress disorder (PTSD) book. Florida: Institute Press. Appendix 1
Mindful Cognitive Processing Worksheet 1. Describe situation briefly 2. List emotions (single words) and rate the intensity (0-100%) 3. List automatic thoughts. Circle “hot thought”. (For deeper work, identify the “core belief. ”) 4. Observe breathing and body sensations. Describe these briefly. 5. Practice acceptance and validation. List thoughts that promote acceptance, non-judgment, validation. Take a few moments to practice breathing in an attitude of allowing things to be as they are without judging or trying to change/fix things. 6. List objective evidence that supports your automatic thoughts. . List objective evidence that counters your automatic thoughts. 8. Identify any distortions involved in your automatic thoughts. 9. Consider a more balanced thought. 10. Describe the outcome. List emotions, rate intensity. List any other reactions, observations. Bonus… 11. Identify any core beliefs that could use revising…. and a more adaptive belief. 12. Consider behavioral experiments to disprove the core beliefs and support a new belief. Summary of some common cognitive distortions: 1. Probability overestimations – overestimating the likelihood of a negative event 2.
Mind reading – assuming what others will think about you Appendix 1 Cont. 3. Personalization – taking too much responsibility for a negative situation 4. Should statements – incorrect/exaggerated statements about how things should be 5. Catastrophic thinking – assuming that a negative event would be catastrophic 6. All-or-nothing thinking (Black ; White Thinking) 7. Selective attention and memory –attend to negative information, discount positive 8. Overgeneralization – a single event is taken as a sign of a global pattern 9. Fortune telling – predicting the future with absolute certainty 10.
Negative core beliefs – negative assumptions about oneself. Taking an event and turning it into a core characteristic. (“I made a mistake” vs. “I am a loser”) 11. Emotional reasoning – believing that if you feel as if something is true, that makes it true (Masson, 2010) Appendix 2 DSM-IV-TR criteria for PTSD In 2000, the American Psychiatric Association revised the PTSD diagnostic criteria in the fourth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (1). The diagnostic criteria (A-F) are specified below.
Diagnostic criteria for PTSD include a history of exposure to a traumatic event meeting two criteria and symptoms from each of three symptom clusters: intrusive recollections, avoidant/numbing symptoms, and hyper-arousal symptoms. A fifth criterion concerns duration of symptoms and a sixth assesses functioning. Criterion A: stressor The person has been exposed to a traumatic event in which both of the following have been present: 1. The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others. . The person’s response involved intense fear, helplessness, or horror. Note: in children, it may be expressed instead by disorganized or agitated behavior. Criterion B: intrusive recollection The traumatic event is persistently re-experienced in at least one of the following ways: 1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed. 2. Recurrent distressing dreams of the event.
Note: in children, there may be frightening dreams without recognizable content 3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: in children, trauma-specific reenactment may occur. 4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. 5.
Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Criterion C: avoidant/numbing Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following: 1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma 2. Efforts to avoid activities, places, or people that arouse recollections of the trauma 3. Inability to recall an important aspect of the trauma 4.
Markedly diminished interest or participation in significant activities 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 (e. g. , does not expect to have a career, marriage, children, or a normal life p) Criterion D: hyper-arousal Persistent symptoms of increasing arousal (not present before the trauma), indicated by at least two of the following: 1. Difficulty falling or staying asleep 2. Irritability or outbursts of anger 3. Difficulty concentrating 4.
Hyper-vigilance 5. Exaggerated startle response Criterion E: duration Duration of the disturbance (symptoms in B, C, and D) is more than one month. Criterion F: functional significance The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: Acute: if duration of symptoms is less than three months Chronic: if duration of symptoms is three months or more Specify if: With or without delay onset: Onset of symptoms at least six months after the stressor (American Psychiatric Association, 2000)
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