1. Veterans may experience compounding traumas from the military context of their experience and exacerbation of stress symptoms from military culture that encourages stoicism and symptom suppression. Dialectical behavior therapy (DBT) focuses on regulating emotions and tolerating distress. This workshop will illustrate the usefulness and difficulties of utilizing DBT with veterans. Healing the Warrior Within: Utilizing Dialectical Behavior Therapy to Restore the Mind, Body, and Spirits of Our Veterans Tweet us at #NASWIL

2. Introduction: Learning Objectives OIF/OEF/OND Treatment utilization Risk of PTSD in the OIF/OEF/OND Population Compounding factors of the military culture Empirical evidence for DBT Why DBT? Tweet us at #NASWIL

3. OIF/OEF/OND Veterans and Treatment Utilization As of September 30, 2011 there are 2.6 million Operation Iraq Freedom (OIF), Operation Enduring Freedom (OEF) and Operation New Dawn (OND) Veterans *12% of the Veteran population 38% access Mental Health Services at a VAMC –-* More than any other era

4. OIF/OEF/OND Veterans and Treatment Utilization Recent conflict Veterans use of Mental Health Services has more than doubled since 2006 –4% to 12% Of those that access Mental Health Services over half access some type of PTSD-related service Very unlikely to complete full treatment protocol –9.5% complete recommended number of sessions

5. Why does this matter? Higher risk for suicide Alcohol and drug use Mental health problems continue to increase Relationship issues Family consequences Isolation from community Vocational consequences

6. PTSD Prevalence in OIF/OEF/OND Population 18.5%-50.2% have a PTSD diagnosis 14-16% have experienced PTSD symptoms Most common diagnostic category: Adjustment reaction 88% PTSD Twice as likely to have an adjustment disorder reaction How can we predict who develops PTSD?

7. PTSD: Defined Post Traumatic Stress Disorder (PTSD) is a maladaptive pattern in the stress response system. Preceded by an individual experiencing a traumatic event in which the person experiences, witnesses or is confronted by an event that involves actual or perceived threat of death, serious injury or a threat to physical integrity of self or others. The traumatic event must meet specific standards and the individual must experience a number of symptoms from the following areas: intrusion, avoidance, negative alterations in cognitions and mood and alteration in arousal and reactivity Symptoms must last a specified length of time, impair functioning and not be in response to a medical condition or substance abuse issue. A diagnosis of PTSD is indicated if an appropriate number of symptoms are present in each category (A= 1 required B=1 required; C=1 required; D=2 required, E=2 required), symptoms last longer than one month, the disturbances creates significant distress or impairment in social, occupational, or other important areas of functioning and they cannot be attributed to a medical condition or substance use issue (APA, 2013).

8. PTSD: Associated Factors Pre-Trauma Factors Trauma Characteristics Post-Trauma Factors Strong AssociationsNoneTrauma/combat exposure severity Perceived life threat Combat-related injury Peritraumatic distress or disassociation Lack of social support, negative homecoming experience, exposure to additional life stressors Intermediate Associations Lower education, lower intelligence, lower military rank, lower socioeconomic status, prior trauma, prior psychiatric history/symptoms, family psychiatric symptoms, family psychiatric history, behavioral problems in childhood, childhood abuse or adversity Exposure to death, Killing or abusive violence

9. PTSD Treatments for Veterans: VAMC Evidenced Based Treatment –Prolonged Exposure –Cognitive Processing Therapy –Cognitive Behavioral Therapy –Medications

10. Influencing Factors for Treatment Utilization FactorsStudy Concerns that treatment will not be kept confidential Treatment will constrain future job assignments and military-career advancement Unpleasant side effects of treatment Mental health care is not effective OIF/OEF/OND feeling out of place at a VA facility Delay or difficulty in scheduling appointments Tanielian & Jaycox, 2008 Stigma and beliefs about mental health careUnited States Government Accountability Office, 2011 Lack of understanding or awareness of mental health careUnited States Government Accountability Office, 2011 Logistical challenges to accessing mental health careUnited States Government Accountability Office, 2011 Concerns about VA’s health careUnited States Government Accountability Office, 2011 Clinic of first mental health diagnosis and distance from VA facility Seal et al., 2010 Type and complexity of mental health diagnosis Seal et al., 2010 Unstable housing, financial distress, unemployment or underemployment, divorce or separation Jakupcak & Varra, 2011

11. Influencing Factors: Military Culture Military Culture –Loyalty, Patriotism, Obedience –Compromised adaptation, flexibility & adjustment skills –Strict roles –Exhibit painful emotions and vulnerability Deployments –Constant separation and reunion –Lack of community integration –Concealment of combat related fears Postwar –Reintegrating into the family system and community –Vicarious trauma –Internal dissonance –Biological memory

12. DBT: Origins Dialectical Behavior Therapy (DBT), developed by Marsha Linehan, Ph.D., ABPP, at the University of Washington In the late 1970s, Marsha M. Linehan (1993) attempted to apply standard Cognitive Behavior Therapy (CBT) to the problems of adult women with histories of chronic suicide attempts, suicidal ideation, urges to self-harm, and self- mutilation.

13. DBT: Origins Clients receiving CBT found the unrelenting focus on change inherent to CBT invalidating Clients unintentionally positively reinforced their therapists for ineffective treatment while punishing their therapists for effective therapy The sheer volume and severity of problems presented by clients made it impossible to use the standard CBT format

14. Cognitive behavioral treatment program developed to treat suicidal clients meeting criteria for Borderline Personality Disorder (BPD) Directly targets: suicidal behavior, behaviors that interfere with treatment delivery and other dangerous, severe or destabilizing behaviors Linehan developed DBT from: restructuring CBT strategies to incorporate acceptance and change with dialectical strategies Definition: DBT

15. Behavioral principles and techniques (CBT), attitude of acceptance embodied in validation, empathy and radical acceptance with relentless focus on problem solving Biosocial Theory regarding BPD Central Problem: emotional dysregulation Emotional regulation is seen as having originated in and as being maintained by a lifelong mutually shaping transaction between a vulnerable temperament and an invalidating environment which leads to deficient emotion modulation skills and motivational problems DBT: Underlying Theory Theory

16. A behavioral, problem-solving focus blended with acceptance-based strategies Emphasis on behaviorally explicit targets and treatment strategy groups Emphasis on dialectical processes DBT: Major Characteristics

17. 1.Increase behavioral capabilities 2.Improve motivation for skillful behavior (through contingency management and reduction of interfering emotions and cognitions) 3.Assuring generalization of gains to natural environment 4.Structure the treatment environment so that it reinforces functional rather than dysfunctional behaviors 5.Enhance therapist capabilities and motivation to treat patients effectively DBT: Addresses 5 functions

18. 1.Weekly individual psychotherapy (1hr/wk) 2.Group skills training (2.5 hrs/wk) 3.Telephone consultation 4.Weekly therapist consultation team meetings (to enhance therapist motivation and skills to provide therapy for the therapists) 5.1 st four sessions are orientation 6.Full protocol is two 6-month rounds of group therapy skills training DBT: Protocol

19. Stage I: decreasing life threatening behaviors, behaviors that interfere with therapy, quality of life threatening behaviors and increasing skills that will replace ineffective coping behaviors. Stage II: addresses the client’s inhibited emotional experiencing. It is thought that the client’s behavior is now under control but the client is suffering “in silence” Stage III: focuses on problems in living, with the goal being that the client has a life of ordinary happiness and unhappiness Stage IV: the goal of is for the client to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and freedom. DBT: Stages

20. Core Mindfulness Skills: Skills to help one experience more fully the present moment Distress Tolerance: Cope better with painful events by building up resiliency and using new ways to soften the effects of upsetting circumstances Emotion Regulation Skills: Help one recognize more clearly what they feel and then to observe each emotion without getting overwhelmed by it Interpersonal effectiveness: New tools to express beliefs and needs, set limits and negotiate solutions to problems Crisis Planning DBT: Group Skills Training

21. Why DBT? Effective in treating suicidal ideations and attempts, self-injurious behaviors, compliance with treatment and problems in daily living activities Associated with better treatment outcomes than treatment as usual Less likely to drop out, require less hospitalization for si, lower medical risk, fewer psychiatric hospitalizations and psychiatric emergency department visits

22. Why DBT with PTSD treatment? DBT with PE has been found to reduce severe and chronic PTSD symptoms DBT may protect against attrition Promotes coping skills for symptoms of trauma treatment (i.e. anxiety, fear, shame, anger, etc.) Promotes safety plan development and problem solving for flooding

23. Why DBT for Veterans with PTSD? Structures mindfulness practice Addresses internal dissonance Radical acceptance Distress tolerance Emotion regulation

24. DBT with Veterans: Challenges Failed to demonstrate superiority when compared to other treatments Evidenced based practice? Not validated as a supplement for PTSD treatment Abstract concept of mindfulness –Resistance to expression

25. Integrating DBT with PE Becker and Zayfert (2001) 1.Skills training is integrated with individual therapy 2.Duration is 5-16 weeks 3.Not participating in the larger DBT program Purpose is to prepare an individual to cope with any flooding issues prior to implementing the therapy Integration can occur at any point during therapy –Serve to regulate emotions, tolerate distress and manage any suicidal impulses

26. References Available Upon Request: elizmorgan33@yahoo.com