Working Effectively with Veterans in the Community

John Straznickas, MD

VA Medical Center, San FranciscoDepartment of Psychiatry, UCSF

Specific ways to increase SUD treatment effectiveness with veterans

Cross-Cultural “Military” SensitivitySpecial Issues with PTSD

Military Culture Take-Home PointsMake an effort to ask and learn about what the military

was like for your patient.Know some basic languageDon’t hesitate to have them teach you

Identify what is your patient’s view of his/her military or veteran experience

Examine your own biasesAssess for weapons

Basic Military HistoryWhich Branch did they serve in?

They are NOT the same!Peace-time or war-time service?Active Duty, National Guard or Reserves?

What was their job/MOS?Involved with combat?

Fire-fights, “being shot at”, mortars.Cooks and truck-drivers saw combat

Unwanted sexual advances?A major risk factor for military women

Not all veterans view their military service the same

Individual differencesCultural differences – Vietnam vs. OEF/OIF

Viewing the Military as a CultureCultural values

HonorRespectLeave no brother behindProtect yourself - weaponsChain of command

Follow orders

Veteran as a ‘Racial’ IdentityHelms’ Racial Identity Model

ConformityDissonance Immersion/Resistance Internalization Integrative Awareness

Slide courtesy of Sam Wan, Ph.D.VA Medical Center, SF

Challenging Ways that Veterans Can Present to Community-Based ProgramsConformity –

Devalues the military and emphasizes the civilian life

Dissonance – Ambivalent about the two ‘cultures’

Immersion/Resistance – Idealization of the military and denigration of the civilian culture

Using this Model to Facilitate Treatment Engagement

The ‘conforming’ veteranDon’t challenge the devaluing…but, Don’t actively join the devaluing

The ‘dissonant’ veteranUse Motivational Interviewing techniques to explore the

‘yes-but’ communicationsThe ‘immersion/resistance’ veteran

Don’t challenge the devaluing…and,Focus on the present problem and solution

Examine Your Own BiasesYour view of warYour view of the soldierYour view of perpetrators of violenceYour view of perpetrators of atrocities

Weapons AssessmentAssume that the veteran has one or more weaponsAssume that their weapons are an important part of

their identityAsk specific questions about how they store the

weapon/s and the bulletsIf suicidality or danger to others is present, negotiate

storing weapons (or just bullets) with a friend and/or getting a trigger lock.

Special Issues with Traumatized Veterans

Substance Use Disorders (SUD)Post Traumatic Stress Disorder (PTSD)

Take Home Points for SUD/PTSD3 C’s: Complex, Confusing and Crisis-prone

Don’t blame them or yourselfExpect an erratic therapeutic alliance

May take multiple treatment contactsExpect more crisis management, more relapses and the

need for repeated intensification of treatment structureHave a good relationship with clinical staff at substance

abuse day hospitals and substance abuse and/or psychiatric inpatient units

Therapeutic Alliance is the primary treatment goal

Reduces distressDiscouragement with poor outcomes

More Difficult to Treat … PLUS Worse Outcomes with SUD/PTSD ptsFewer clinical improvements, more crisesUneasy alliance, negative counter-

transferencesPoorer compliance with aftercare treatmentsShorter time to relapse post-treatmentDrink more on drinking daysMore medical and interpersonal problemsMore homelessness

Druley and Pashko 1988, Nace 1988, Brown and Wolfe 1994, Saladin et. al. 1995, Breslau et. al. 1997, Ouimette et. al. 1999, Najavits 1998

Why the Difficulties and Poorer Outcomes?

A double dose of distress

Similar Neurobiologic Abnormalities in SUD & PTSD

Deficits in titrating level of arousalDisease exacerbation with stress

SUD relapse PTSD increase in intrusions and arousal sx

Cue-induced behavioral symptomsOver-values and generalizes dangers of PTSD triggersUnder-values and fails to generalize dangers of SUD

cues

Common Therapist Barriers in Forming an Alliance with SUD/PTSD Patients

Therapist’s resonance and sympathy with the patient’s state of heightened anxiety and distress leads to fearful treatment thoughts:Fear of SUD relapse if PTSD is addressedFear of losing the alliance for PTSD work if

SUD is addressed.Tuned-out style of patient’s interactions

Difficult for therapist to engage in alliance

Therapist Suggestions for Working with SUD/PTSD PatientsNon-confrontational & Respectful style

‘Parental stance,’ extensive processing of Counter-transference

Strongly expressed empathyFlexible approach allowing patients to process multiple

traumatic events at a slower, ‘stop & go’ paceKnowledge of PTSD and SUD treatment approachesAn explicit, extensive written set of safety parameters for

Impulsive behaviors, and Relapse-prevention during PTSD treatment

Know methods to overcome non-functional resistance to exposure work. Back et.al (2001) and Najavitis et.al (2008)

Common Therapist Barriers in Forming an Alliance with SUD/PTSD PatientsDichotomous Thinking in Therapist

Sympathetic victim schema: PTSD is a disorder from an accident

Unsympathetic/Repulsive schema: SUD is a disorder of (bad) choices

Dichotomous / Non-Integrated Training of CliniciansSUD and PTSD seem to exist in different universes“I don’t know nothin’ about birthin’ no babies PTSD

interventions.”No empirical support for an integrated training model

(Brady et al., 2001).Clinical treatment programs operate under separate

funding for general psychiatry and substance use disorders.

Reluctance by PTSD Patients and Therapists to Initiate SUD Treatment Psychosocial and public nature of SUD work.Confrontation of addictive behaviors by some treatment

programsIncreases arousal (and hostility)

12 Step Challenges to a Military MindLoss of Control: AA’s core tenet that life has become

unmanageable from Alcohol and that they have ‘lost control’Surrender: Concept of a ‘Higher Power’ and ‘Surrender’Forgiveness: Fearless moral inventory and making amendsAnonymous Group: AA’s crowd of strangers and the telling

of ‘war’ stories

Evidence for Benefit of PTSD Treatment for SUD PatientsFollowing Inpatient SUD treatment, the amount of

PTSD outpatient treatment (3 months or longer) was a major predictor of sustained SUD remission. Ouimette, Moos, Finney 2000

Following Inpatient SUD treatment, partial hospital PTSD Combat trauma processing group showed sustained improvement in PTSD and SUD measures. Donovan 2001

Psychopharmacology for SUD/PTSD

PTSD Evidence-based medication treatments Sertraline ParoxetineFluoxetine

PTSD Medication trials with ‘few data’: Prazosin Citalopram Fluvoxamine Escitalopram

Davidson 2005

Psychopharmacology for SUD/PTSDPTSD Medications with ‘some data’:

VenlafaxineMirtazapineRisperidone

Ineffective PTSD Medication: Bupropion

Davidson 2005

General Rules for Med TrialsFor PTSD patients:

Go low and slow to minimize anxiety side-effectsFor SSRIs 2-12 weeks for 50% reduction in symptoms Improvement continues up to 6 months for a 70% reduction

Davidson 2005

For SUD/PTSD patients:Same as aboveSometimes for agitation & sleep – go Fast and Heavy

Topamax ? Less use of Quetiapine