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| Trauma and Substance Abuse: Guidelines for Treating Returning Veterans |
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| Feature Articles - Treatment Strategies or Protocols | ||||||||||||||||||||||||||||||||||
| Written by Donald Meichenbaum, PhD | ||||||||||||||||||||||||||||||||||
| Saturday, 01 August 2009 00:00 | ||||||||||||||||||||||||||||||||||
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Editor’s Note: This article is the first in a two-part series on trauma and substance abuse in returning veterans. It introduces guidelines for treating returning veterans, while the second article will focus on practical ways to implement these treatment guidelines.
About 1.6 million men and women have served in Iraq and Afghanistan since the start of military operations in 2001. One-third of deployed soldiers have served at least two tours of duty; 70,000 have been deployed three times; and 20,000 have been deployed at least five times. The more times soldiers are deployed, the greater the likelihood of mental disorders. Multiple deployments are associated with a 50 percent greater prevalence of psychiatric disturbance. A recent RAND Corporation study estimated that as many as 300,000 returning veterans are suffering from post- traumatic stress disorder (PTSD) and/or depression, often complicated by the presence of traumatic brain injuries, as a result of exposure to improvised explosive devices (IEDs). (See Tanielian & Jaycox, 2008; RAND, 2008, http:// veterans.rand.org). Approximately 1,000 returning veterans commit suicide each year, which is twice the likelihood of their civilian counterparts. The risk of suicide is significantly heightened when a substance use disorder (SUD) is present. The need to conduct early identification and interventions with returning soldiers from Iraq and Afghanistan is underscored by the findings on Vietnam veterans. Up to 50 percent of Vietnam veterans who developed PTSD continue to have it decades later. As Friedman and Davidson (2007) observe: “Male Vietnam veterans in VA settings are a particularly chronic and treatment-refractory cohort who appear unlikely to benefit from pharmacotherapy or from psychosocial treatments. These findings are a strong argument for early detection and treatment of PTSD, because decades of chronicity appear to reduce the prognosis for a favorable outcome.”
Among male Vietnam veterans who met the diagnostic criteria for PTSD, 73 percent also qualified for a lifetime diagnosis of alcohol abuse or dependence; and 25 to 56 percent have a lifetime drug abuse/dependence. Such lifestyle behaviors exacerbate chronic PTSD. Among female Vietnam veterans, a PTSD diagnosis predicts greater than five-fold increase in alcohol abuse and dependence. Both male and female veterans who meet the criteria of alcohol abuse or dependence suffer more impairment and thus, are less likely to be gainfully employed; less likely to marry; have multiple divorces; greater parental difficulties; be socially isolated; and are more prone to violence. When considering the relationships between PTSD, SUDs and other psychiatric disorders, it is important to appreciate that in some instances PTSD can follow SUDs, and in some instances SUDs can precede PTSD. This sequence may be influenced by the specific cohort of soldiers or by the gender of the individual. For instance, in the case of World War II veterans, SUDs followed PTSD by a mean of 6.9 years, while SUDs preceded PTSD in Vietnam veterans by 3.1 years. In the case of gender, women are more likely than men to develop SUDs subsequent to trauma exposure and PTSD, with approximately 65 to 84 percent of women meeting criteria for PTSD before they develop SUDs. This pattern suggests that women self-medicate or cope with trauma-related symptoms by using substances. In men, the temporal pattern is more consistent with an increased risk for trauma exposure during the course of substance use and abuse, which then leads to PTSD. Gender bears special attention in formulating treatment plans. Female veterans, PTSD and substance abuse More than 160,000 women (1 in 10 soldiers) have been deployed to Iraq and Afghanistan. They experience more lethal attacks than American women in any other war. In addition to the stress of combat exposure, female soldiers are more likely to also experience sexual harassment (66 percent) and sexual assault (23 percent) (a “double whammy” of combat exposure and sexual abuse). Only 10 to 30 percent of female soldiers who are sexually assaulted, report it to military officials. Female veterans who reported being sexually assaulted in the military were found to be twice as likely to screen positive for symptoms of alcohol abuse than those who were not assaulted. Moreover, women with PTSD and alcohol abuse are more likely to report a history of childhood sexual abuse and they report having experienced a greater number of childhood traumas. Female sexual assault survivors are five times more likely to overuse prescription drugs; three times more likely to use marijuana; six times more likely to use cocaine; and 10 times more likely to use other hard drugs than women who have never been assaulted. They are 13 times more likely to have serious problems with alcohol. Usually, a more vicious sexual assault results in a more severe SUD problem. Females who are victims of sexual assault also are more likely to present with dissociative and borderline personality disorder symptoms (Kimerling, Ouimette & Wolfe, 2002; Ouimette & Brown, 2003). Rape is the traumatic event that is most likely to lead to PTSD and comorbid disorders in both women and men. One-third of female veterans seeking mental health care said they experienced rape or attempted rape during their service. Of that group, 37 percent reported they were raped multiple times; and 14 percent reported they were gang-raped. The data on trauma and women take on specific relevance when we learn that there is a stronger link between PTSD and SUDs in women than in men. Najavits (2002) observed that women who have been victimized are two to nearly four times more likely to evidence comorbid disorders than men. Moreover, women who have been traumatized have: • a more rapid onset of substance abuse than women who have not been traumatized; • an increased likelihood of experiencing PTSD symptoms with initial abstinence and increased vulnerability to relapse; • a greater likelihood of having experienced repeated traumas (prior to age 18), more self-blame, suicide attempts, revictimization (such as intimate partner violence), sexual dysfunction and a higher incidence of other comorbid psychiatric and medical disorders; and • more difficulty establishing a therapeutic alliance, compliance difficulties and a lower motivation for treatment than women who have not been traumatized. The relationship between victimization, PTSD and SUDs is not limited to military personnel. Table 1 provides illustrative data for a variety of diverse populations. In accordance with these findings we can consider the implications for assessment, case formulation and treatment decision-making. Clinical implications
Given the findings enumerated in Table 1, what are the implications for both assessment and treatment decision-making? In other words, what should you take away from these epidemiological findings on the complex relationships between trauma and exposure and SUDs?
1. There is an explicit need to regularly assess for comorbid disorders in psychiatric patients, and especially in returning soldiers. Eighty percent of patients with PTSD have at least one comorbid disorder; and 60 percent of psychiatric patients receive three or more psychiatric diagnoses. Studies of Vietnam veterans found 73 percent comorbidity with substance abuse; 31 percent with antisocial personality disorder; and 28 percent with major depression. Nevertheless, such comorbidity is often overlooked by clinicians. Mueser and his colleagues (1998) found that 43 percent of the sample of psychiatric patients had PTSD, but only three of 119 had this recognized in their clinical charts. 2. There is a need to conduct a life-span assessment to determine the developmental interplay and interdependence of PTSD, SUDs and other psychiatric and medical disorders. Which disorder emerges in what order, and how did these disorders “spiral downward” to maintain and exacerbate each other? 3. There also is a need to assess for nonchemical repetitive habituating behaviors that may suppress traumatic stress symptoms (e.g., high risk-taking “adrenaline rush” thrill-seeking behaviors such as risky driving, illegal activities, sexual acting out, compulsive gambling, physical overexertion, workaholism). These behaviors may help the veteran to protect oneself by numbing out—escaping and detaching from painful recollections of the war; or escaping from the boredom of everyday life and feelings of disconnection from society. Such behaviors may interfere with occupational and societal obligations and undermine achieving personal goals. For some veterans, they may become preoccupied with war-related reminders (namely, news accounts, movies, paraphernalia and clothing related to war experiences). Davidson and Scurfield (1994) highlighted that such repetitive behavioral patterns can become a “survival mode.” 4. Any lifespan assessment also should include genogram data on the incidence of trauma exposure and SUDs on the client’s family members, as well as an ecological assessment of any environmental traumatic events that could have resulted in a loss of resources, which can contribute to PTSD-SUDs linkage. 5. There is a need to inquire about the returning soldier’s wartime experiences in a supportive, nonjudgmental fashion in order to determine the presence of risk and protective factors. For instance, exposure to grotesque death (e.g., mass deaths, mutilation, body handling) is highly predictive of PTSD and SUDs. Did the chemical dependence have an onset while in combat, beforehand or during post-deployment? Among males, the most common traumas associated with SUDs are combat and crime victimization; whereas among females, they are childhood physical and sexual abuse. 6. There is a need to conduct a life span history of multiple victimization experiences and assess current safety needs, given the high likelihood of revictimization. High-risk trauma-induced experiences may contribute to further substance abuse. 7. There is a need to conduct a careful polysubstance abuse assessment, both developmental and current (namely, years of substance use, symptoms, functional impact, treatment experiences). There is a need to assess the soldier’s motivation to abstain with regard to all substances, and collaboratively establish treatment goals for all substances separately. Soldiers may be willing to work on discontinuing usage of some substances, but not others.
8. There is a need to assess the current adjustment problems that may involve legal, medical and social arenas. What are the potential stressors, challenges and barriers to treatment? For example, is the soldier experiencing the aftermath of a post-concussive disorder and traumatic brain injuries that might complicate and compromise treatment and prognosis? Should the treatment have a “here and now” focus to improve quality of life?
9. There is a need to also assess for the client’s “strengths”—survival skills, signs of resilience—that can be incorporated into treatment. These include both individual, social and systemic (social, capital strengths). 10. There is a need to monitor the potential for developing and maintaining a good therapeutic alliance. Obtain a treatment nonadherence history in order to anticipate potential obstacles and the risk of dropping out of treatment. Should Motivational Interviewing procedures be employed with this soldier? (See Murphy, 2008 and www.motivationalinterview.org) 11. There is a need to conduct risk assessment toward oneself (suicidal potential) and risk toward others, given the high incidence of acting out behaviors in this dually-diagnosed clientele. 12. Finally, there is a need to decide if the treatment plan should be conducted in a parallel, sequential or integrated fashion, which is the topic of the companion article (Part Two). In the second part of this article, we will consider practical ways to implement these treatment guidelines. How can we be of help to Bob, Sarah and Tom? When formulating these treatment plans, there is a need to keep these findings in some perspective. The research also tells us that the overall prognosis of PTSD soldiers is quite positive, as complete recovery can occur by three months in approxi mately half of these cases. More over, longitudinal data indicates that returning soldiers from World War I to the present, tend to be quite resilient and relative to their civilian counterparts; the returning soldiers evidence more successful adjustment, academic and occupational success; less incarceration; and better social relationships. As Freeman, Moore and Freeman (2009) highlight, 85 percent of soldiers who return from combat do not evidence long-term clinical problems. The challenge for mental health workers is how to assist those who seek our help to develop and employ the coping skills, and in some cases, even demonstrate post-traumatic growth of their “Band of Brothers.” As examples of how to bolster re-silience in returning soldiers and their families, visit the website www.warfighterdiaries.com, and watch the HBO documentary film, Alive Day Memories, in which actor James Gandolfini (a.k.a. Tony Soprano) interviews veterans who have returned from Iraq. The data entered in Table 1 are based on reviews offered by Drummond et al. (1995), Freeman et al. (2009), Friedman et al. (2007), Gomberg (1999), Kimerling et al. (2002), Najavits (2002) and Ouimette & Brown (2003).
Donald Meichenbaum, PhD is Distinguished Professor Emeritus, University of Waterloo, Ontario, Canada, from which he retired 15 years ago. He is now Research Director of the Melissa Institute for Violence Prevention and Treatment of Victims of Violence in Miami, (See www.melissainstitute.org), and is one of the founders of Cognitive Behavior Therapy. Dr. Meichenbaum was voted “one of 10 the most influential psychotherapists of the 20th century” by North American clinicians. He is presently working on a major project for the military in creating a website on resiliency with downloadable IPOD technology for soldiers and their families (see www.warfighterdiaries.com). He also conducts five-day workshops on treating victimized individuals and has written a Clinical Handbook on Treating PTSD. He can be reached at
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References
Daniels, L.R. & Scurfield, R.M. (1994). War-related post-traumatic stress disorder: Chemical addictions and nonchemical habituating behaviors. In M.B. Williams and J.F. Sommer (Eds.), Handbook of post-traumatic Therapy, (pp. 205-220). Westport, CT: Greenwood Press. Drummond, D., Tiffany, S., Glautier, S. & Remington, B. (1995). Addictive behavior: Cue exposure therapy and practice. Clichester: J. Wiley & Sons. Freeman, S.M., Moore, B.A. & Freeman, A. (Eds.) (2009). Living and surviving in harm’s way: A psychological treatment handbook for Pre- and Post-deployment of military personnel. New York: Routledge Publishers. Friedman, M.J. & Davidson, J.R. (2007). Pharmacotherapy for PTSD in M.J. Friedman, T.M. Keane and P.A. Resick (Eds.) Handbook of PTSD: Science and Practice. (pp. 376-405). New York: Guilford Press. Friedman, M.J., Keane, T.M. & Resick, P.A. (Eds.) (2007). Handbook of PTSD: Science and Practice. New York: Guilford Press. Gomberg, E.S. (1999). Women. In B.S. McGrady & E.E. Epstein (Eds.), Addictions: A comprehensive guidebook (pp. 527-541). New York: Oxford University Press. Kimerling, R., Ouimette, P., & Wolfe, J. (Eds.) (2002). Gender and PTSD. New York: Guilford Press. Mueser, K.T., Goodman, L.B., Trumbetta, S.L., Rosenberg, L.D., Osher, F.C., Vidaver, R., Auciello, P. & Foy, D.W. (1998). Trauma and posttraumatic stress disorder in severe mental illness. Journal of Consulting and Clinical Psychology, 66, 493-499. Murphy, R.T. (2008). Enhancing combat veterans’ motivation to change posttraumatic stress disorder symptoms and other problem behaviors. In H. Arkowitz, H.A. Westra, W.R. Miller & S.S. Rollnick (Eds.), Motivational interviewing in the treatment of psychological problems (pp. 57-84), New York: Guilford Press. Najavits, L.M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York: Guilford Press. Ouimette, P. & Brown, P.J. (Eds.). (2003). Trauma and substance abuse: Causes, consequences and treatment of comorbid disorders. Washington, DC: American Psychological Association. Tanielian,T. & Jaycox, L. ( Eds.).(2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences and services to assist recovery. Santa Monica,CA: Rand Corporation.
This article is published in Counselor, The Magazine for Addiction Professionals, August 2009, v.10, n.4, pp.10-15.
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