Workshop Objectives Overview of the common symptoms of PTSD. Overview of the common problems in children of veterans with PTSD including some common mechanisms of vicarious experiences of PTSD in children. Identify interventions for children who may be experiencing indirect effects of their parents traumatization while deployed. Overview of the effects of PTSD on the couple’s relationship. Describe a recovery–based psycho-education model that provides families with resources that will help them manage and cope more effectively with their loved one’s PTSD. There are different ‘RECOVERY MODELS’ from which to choose, and I am not going to go into the history of these today. (For example, scientific models, consumer models, etc.). Today we are really going to focus on an overview of what it means to provide ‘RECOVERY-ORIENTED MENTAL HEALTH CARE,” and why that is important. I will note, however, that in my new job position that I will tell you about in a moment, I am looking to put together a CURRICULUM on mental health recovery, so I’ll be interested in your ideas for future presentations.

The effects of PTSD on the Family Veterans suffering from PTSD or other forms of post-traumatic stress have symptoms that can become catastrophic for families. Catastrophic stress is sudden, unexpected and produces frightening experiences that are often accompanied by a sense of helplessness, destruction, disruption and loss.

What distinguishes this loss from “normal” loss is there is little time to prepare for it, no previous experience, no guidance, feeling isolated, remaining in crises for long period of time, lack of control, disruption and destruction and high emotional impact.

Post Traumatic Stress Disorder A. 1. The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. 2. The person’s response involved intense fear, helplessness or horror.

PTSD (continued) B. The traumatic event is persistently re-experienced in one or more of the following ways: Recurrent and intrusive images Recurrent distressing dreams of event. Acting or feeling as if the traumatic event were recurring Intense psychological distress at exposure to internal or external cues Physiological reactivity

PTSD (continued) C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness. Efforts to avoid thoughts, feelings or conversations associated with the trauma. Efforts to avoid activities places, or people that arouse recollection of the trauma. D. Marked avoidance of stimuli that arouse recollections of the trauma

PTSD Symptoms Re-experiencing Traumatic Events Avoidance and Numbing Symptoms Hyperarousal – Easily Startled Irritability and Anger Avoidance of Activities Difficulty Concentrating Difficulty with Trust

Research Findings of Vicarious Influence of PTSD in Veterans Extensive research with family members of Vietnam Veterans in the last 20 years has revealed there can be serious consequences on the family of veterans with PTSD.

Effects of Veteran’s Symptoms on Children

Re-experiencing the Trauma Children may be frightened by watching a parent re-experiencing their symptoms. Children likely do not understand what is happening, and they may start to worry about their parents well-being. Children also may be fearful that their parents cannot properly care for them.

Emotional Numbing A common response to PTSD, Emotional numbing may prevent the Veteran from experiencing positive emotions toward family members. As a result, children may feel unloved or assume that their parent is angry toward them.

Avoidance of Social Activities Parents with PTSD often avoid activities outside the home, including activities with their children. As a result of this lack of involvement, children may feel that their parents do not care for them. Social avoidance and emotional numbing influence the satisfaction that parents with PTSD experience from parenting.

Hyperarousal Symptoms Living with someone who is expressing high levels of anxiety and arousal, as well as being constantly on guard for danger, often results in the child developing the belief that the world is a dangerous place – one in which he/she needs to be fearful.

Irritability and Anger Children living with individuals who exhibit constant irritability often results in children feeling unloved by their parents. Research has found that this creates barriers to and prevents close family relationships. Increased potential for violence in the home.

Co-Occurring Substance Abuse Substance abuse is often a co-occurring condition in veterans with PTSD (i.e., 50% of veterans). Substance abuse alone results in an array of psychological trauma for children that has been well documented in research and clinical literature.

Common Problems in Children Social and Behavioral Problems Depression, Anxiety Hyperactivity & Difficulty with Concentration Difficulty forming and maintaining friendships. Nightmares about parent’s trauma. Secondary PTSD related to violence in the home.

Patterns of the Direct Effects of PTSD on Children Over-identified child- experiences secondary traumatization and comes to experience many of the symptoms the parents is having. Rescuer-child takes on parental roles and responsibilities to compensate for the parent’s difficulties Emotionally uninvolved child-this child receives little emotional support and does not learn how to appropriately cope with emotions, which results in problems at school, depression, anxiety, and relationship problems later in life.

Problems in Adolescence Poor Attitude and lack of motivation at school. Negative attitude toward fathers and other “authority figures”. Higher levels of depression and anxiety. Lower creativity and described as not working up to their ability. Problematic behavior at home and at school.

Culture of Silence Children are taught to avoid discussion of events, situations, thoughts, or emotions related to their parent’s experience. They perceive this is a taboo subject and resist asking questions. This tends to increase their anxiety as they often worry about provoking the parent’s symptoms. Because a child does not understand the parent’s symptoms, or have details about the traumatic event, the child may develop ideas that are even more horrifying than what actually occurred.

Overdisclosure When children are exposed to graphic details about their parents’ traumatic experience, they may start to experience their own set of PTSD symptoms in response to horrific images generated. This has often been referred to as vicarious traumatization. If we switch then to MENTAL HEALTH RECOVERY Recovery is a PROCESS in which the person engages to figure out how to manage and live with his or her disorder (Davidson et al. 2006). This supports that recovery is not always LINEAR – there are set-backs along the way. Thinking about the previous primary care recovery models, some MH examples may be: ACUTE CONDITIONS: Single major depressive episode is an example of a person who may recover without any residual sx. FOR THOSE PEOPLE, RECOVERY REALLY MEANS ‘CURE’ VULNERABILITY: A person who has a second Major Depressive episode, maybe resulting in hospitalization, they may be without residual sx but have a vulnerability for a future episode. For such persons, RECOVERY really includes LIFESTYLE ADAPTATIONS, maybe medication, monitoring, etc. CHRONIC/INTERMITTENT: For other persons, for instance with bipolar disorder or some persons with schizophrenia, they may experience their mental health condition as chronic, but with long term intermittent symptoms. Recovery = education, monitoring, adaptation, medication. CHRONIC/PERSISTENT: Still other mental health conditions may present as chronic with persistent symptoms, such as a person with schizophrenia or a mood disorder that maintains some level of persistent symptoms. . Recovery = treatment, illness management, rehabilitation and accommodation

Identification Children may start to identify with the parent to such a degree that they begin to share in his or her symptoms as a way to connect with the parent.

Re-enactment Children also may be pulled to re-enact some aspect of the traumatic experience because the traumatized parent has difficulty separating past experiences from present. How we frame RECOVERY, is NOT BY OUTCOME – it is by APPROACH. So…with this – TODAY – we are going to talk about our role & responsibilities in as mental health providers, and reviewing our practice for strategies that we can adopt to provide ‘recovery-oriented’ service to our consumers. Again, think of it as having a recovery-oriented perspective. . .

Major Tasks for Returning Veterans That Present Challenges for the Family Redefining Roles, Expectations, and Division of Labor. Managing Strong Emotions. Abandoning Emotional Constriction Creating Intimacy in relationship Creating a Sense of Shared Meaning Surrounding Deployment Experience.

Adjustment Issues with Deployment ….a traumatized soldier often returns to a traumatized family and neither is recognizing the other” (Hutchinson & Banks-Williams, 2006, p. 67)

Adjustment Issues (continued) Some adjustment issues resolve on their own. Often, however, returning soldiers can exacerbate the family’s trauma, (resulting from the deployment experience), because they have difficulty connecting to others, have sleep problems, and miss the structure and camaraderie of military service. Divorce rates among active duty Army officers tripled between 2001 and 2004. Rates among enlisted men increased by 50%. Domestic violence rates among military personnel increased also (Perry & Flournoy, 2006).

Impact of PTSD on the couple’s relationship Short and long-term disruptions to intimacy. Increased difficulties with trust. Avoidance of partner. Preoccupation with guilt, shame and self-blame. Difficulty accessing and managing emotions . Isolating and withdrawing from partner. Increased use of drugs/alcohol.

Couples who manage to cope more effectively with issues Can identify their problems and express their commitment to resolve them without imposing strict rules about how and when to address them. Utilize skills that address the issues without blaming or judging each other. Have identified others they turn to for support

Changes in VA Practices in Working With Families In reaction to the research that has identified the impact of PTSD on family members of Vietnam Veterans, the military, VA, other organizations (SAMSHA, NAMI, etc.) are addressing issues related to children and families of the current returning veterans through education and treatment.

VA Strategies for Preventing Vicarious Effects of PTSD Interventions: Development and/or incorporation of evidence-based practices for the treatment of PTSD. Early screening for returning veterans with free treatment for a period of five years. Preparing families for mobilization, deployment, and return. Availability of treatments for veterans that incorporates family interventions. Efforts to reduce stigma associated with treatment. TURNING BACK TO THE PRESENT DAY… The defined GOALS then address the following: PARITY & a HOLISTIC view– that mental & physical health are a part of EVERY PERSON That there should be PARITY in treatment and services (e.g. mental health parity in insurance coverage) That we’ll do early detection & screening, and use best practices and technology in treating. I’m going to comeback to the HIGHLIGHTED goal that mental health care is “consumer & family driven”, because that will be the focus of what we’re talking about today. IN SHORT, since the PNFC report, there has been a tremendous emphasis on making sure that healthcare policies and practices are promoting “RECOVERY”, and (thus) that we have a SYSTEM TRANSFORMATION to implement recovery-oriented care.

Recovery-based Model: Core elements Psycho-education: PTSD and it’s effects A Strength-based approach Creating a support network Instilling hope Tools to help families manage “crises”.

What Are the Implications for Treatment of Children of Veterans with PTSD Do not confuse the secondary symptoms with primary symptoms and provide treatment only to the child. Assess for domestic violence, child abuse, overdisclosure, or other forms of exposure of the child to violence. Examine assessment tools for exploring trauma issues i.e., International Society for Traumatic Stress Studies (ISTSS) Resources for Clinicians list (ISTSS, 2007). Educate the parent(s) about the potential influence of PTSD symptoms on children.

Implications for Treatment (continued) Encourage the parent to explain the reason for the parent’s difficulties without providing graphic details. (children should see that symptoms are in no way related to them). Provide information on resources to help the parent know how to prevent transferring their symptoms or the consequences of their symptoms to their children. Veteran Centers (www.va.gov/rcs/) Veterans Affairs (www.va.gov) National Center for PTSD (www.ncptsd.va.gov)

Implications for Treatment (continued) Encourage the veteran to seek treatment first so that other family members’ involvement should be viewed as an adjunct therapy that provides support and education. Depending on the degree of symptoms and age, individual therapy with the child may be indicated. Regardless of treatment suggestions, it is important that each person in the family have a voice in expressing his or her concerns.

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