Marijuana Vs. Pain, Anxiety and Depression

Operation Vet Fit is recruiting men and women over the age of eighteen to volunteer to participate in a ground breaking study on Marijuana. Interested participants may anonymously register for the study here. Study participants remain anonymous and identities remain confidential. Participants will utilize their own marijuana for the study. Marijuana will not be provided by our research team.

Study participants will be asked to complete a series of questions prior to and following their use of marijuana. The entire process take less than 1 hour to complete and can be done wherever the participant is most comfortable utilizing marijuana. Participants will be able to complete the study via computer or smart phone at any time following submission of this registration. 

Upon submission of registration, participants will be provided with website links and passwords to anonymously complete the study. 

What State do you live in? (this question is optional but it will help us with better demographic data analysis)
This is an optional question but will help us better understand our population sample.
Please let us know if you are a recreational or medicinal user of Marijuana. (Medicinal would require a medical card, recreational would not)
Feel free to provide any information about yourself that might be helpful to researchers. This is an optional field.

Research Study: Veterans and Marijuana

Abstract

On April 20th, 2018 Operation Vet Fit conducted a first-of-its-kind marijuana research study to investigate if marijuana demonstrates measurable medicinal values in outcomes on depression, anxiety and pain amongst US Military veterans.

Background

Marijuana is still federally classified as a Schedule 1 drug based on its designation of having, "no medical use and a high potential for abuse". Further, that marijuana, under Schedule 1 classification, is considered as dangerous as: "heroin, lysergic acid diethylamide (LSD), methylenedioxymethamphetamine (ecstasy), methaqualone, and peyote" (DEA).

Moreover, marijuana's classification also identifies it as more dangerous than: "Vicodin, cocaine, methamphetamine, methadone, hydromorphone (Dilaudid), meperidine (Demerol), oxycodone (OxyContin), fentanyl, Dexedrine, Adderall, Ritalin, Tylenol with codeine, ketamine, anabolic steroids, testosterone, Xanax, Soma, Darvon, Darvocet, Valium, Ativan, Talwin, Ambien, and Tramadol" (DEA).

Marijuana's schedule 1 classification also makes medical research elusive, if not impossible due to institutional fears of shut-down, loss of licensure, defunding and criminal prosecution. Such concerns have created barriers to research making data on the plant's medical impact hard to attain from credible agencies such as the Veterans Affairs (VA) and United States college and university research teams. This lack of available and credible data have stifled lawmakers' attempts to reclassify the plant as medicine rather than a dangerous and addictive drug. 

Currently, twenty veterans commit suicide daily.  And while the VA's current "best practices" for pain management and PTSD include prescribing a cocktail of medications, including dangerous opioids that are highly addictive, veterans living in states with medical marijuana laws are coming forward, sharing their stories of freeing themselves from opioids by choosing medical marijuana as the alternative. 

The timing of this study comes as the President of the United States has declared the opioid overdose and addiction epidemic a national emergency. 

The goal of our agency's research herein is to measure marijuana's impact on pain, anxiety and depression. To do so we will be utilizing our combat veteran population living in states where they are legally able to attain medical marijuana. Should this study infer a medical benefit, further research amongst our more highly funded and independent institutions can and should follow. 

Method

Participants - Thirty-two veteran members of the United States Armed Forces were recruited via social media. Veteran status was verified via confidential submission of participants' DD214 (Certificate of Release or Discharge from Active Duty) with names and Social Security numbers omitted. Of the thirty-two original registrants, ten did not submit a copy of their DD214 making them ineligible to participate in this study.

As a result, twenty-two verified US Armed Forces Veterans were provided with direct website links to complete pre and post measures (BDI, BAI, Pain Scale), just prior to and following their marijuana utilization.

Of those twenty-two provided the web links to the anonymous pre and post surveys, only eleven completed the pre measures. Of them, ten completed the post measures.

The identities of those completing the measures remained annonymous throughout and following the study conclusion. Only those who provided a copy of their DD214 were granted website links and password access to the measures for completion. 

Additionally, we collected data on each participant's current VA disability rating, as well as their VA disability rating for PTSD and total number of years they have been utilizing marijuana to treat their symptoms. 

Population Demographics - Of the 22 initial participants, 21 were male. Average age was 38 with a (SD=10.58). Ages ranged from 25-62 years. Nine of the participants were engaged by or engaged the enemy in combat (Combat Action). Of those nine, average combat theatre exposure was 14 months (SD= 10.07) with 33 months in theatre being the lengthiest observed participant. Eleven participants served in a combat theatre but did not engage in combat action. Average population deployment time total was 13 months (SD=15.11). Five subjects never deployed. Of those who did deploy, average deployment time total was 17 months (SD=15.35). The subject with the lengthiest deployment history served 59 months overseas. Average rank of all participants was E4 (SD=1.5), with only enlisted veterans making up the total population. All but one of the participants had a VA disability rating. Average VA disability rating of the population group was 70% (SD 30.01) with 73% having a VA diagnosis and rating for PTSD. No officers participated in this study. Six of the participants served in Iraq, five served in Afghanistan, two in Somalia, and one in the Gulf War. 

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Measures Used:

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Post Traumatic Stress Disorder (PTSD) - Rating was based on veterans' VA determination of severity as provided by the participant. VA ratings for PTSD require exhaustive evaluations using both objective and subjective measures. The reliability of a VA rating is far superior than requiring the the veteran to complete a separate individual subjective questionnaire. For these reasons we are avoiding the use of additional PTSD measures.

Depression - Was measured using the Beck's Depression Inventory (BDI) taken prior to and following utilization of medical marijuana. Pre marijuana utilization scores for depression in the population sample demonstrated a mean of 24.18 n=11; (SD=13.98) placing the population sample, prior to using marijuana,  within the second highest depression category of "Moderate Depression"(Beck et al., 1988). 

The Beck Depression Inventory (BDI) is a 21-item, self-report rating inventory that measures characteristic attitudes and symptoms of depression (Beck, et al., 1961). Internal consistency for the BDI ranges from .73 to .92 with a mean of .86. (Beck, Steer, & Garbin, 1988). The BDI demonstrates high internal consistency, with alpha coefficients of .86 and .81 for psychiatric and non-psychiatric populations respectively (Beck et al., 1988).

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Anxiety- Was measured using the Beck's Anxiety Inventory (BAI) taken prior to and following ingestion of medical marijuana. Pre marijuana utilization scores for anxiety in the population sample demonstrated a mean of 23 (n=11); (SD=17.29) placing the population sample, prior to using marijuana, within the category of "Moderate Anxiety"(Beck Epstein, Brown & Steer 1988).

The Beck Anxiety Inventory (BAI), created by Aaron T. Beck and other colleagues, is a 21-question multiple-choice self-report inventory that is used for measuring the severity of anxiety in children and adults. The questions used in this measure ask about common symptoms of anxiety that the subject has had during the past week. Several studies have found the Beck Anxiety Inventory to be an accurate measure of anxiety symptoms in children and adults (Leyfer, Ruberg, & Woodruff-Borden, 2006 ). The Beck Anxiety Inventory is a well accepted self-report measure of anxiety in adults and adolescents for use in both clinical and research settings (Groth-Marnat, 1990). The BAI is psychometrically sound. Internal consistency (Cronbach’s alpha) ranges from .92 to .94 for adults and test-retest (one week interval) reliability is .75 (Beck Epstein, Brown & Steer 1988).

Pain - Was measured utilizing the Universal Pain Assessment Tool below taken prior to and following ingestion of medical marijuana. Pre marijuana utilization scores for pain in the population sample demonstrated a mean of 4.91 n=11; (SD=2.23) placing the population sample, prior to using marijuana, within the "Moderate Pain" category.

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The Universal Pain Assessment Tool (UPAT) combines the advantages of four types of pain assessment instruments – Visual Analogue Scale, adjective scales, Numerical Rating Scales (NRS) and Faces Scales. The Universal Pain Assessment Tool aims to describe completely the individual's pain experience. The combination of NRS, verbal description, association between pain and facial expression and individual threshold of pain makes this instrument usable in all age groups (Hockenberry, Wilson, Wilkenstein & Wong, 2005; Hesselgard, Larsson, Romner, Strömblad &, Reinstrup, 2007; Edelen & Saliba, 2010).

Results

Marijuana utilization amongst the population sample in this study demonstrated significant reductions in pain, anxiety and depression for 100% of the participants. Graphical results of pre and post marijuana utilization amongst our population sample have been provided below.  

 

Discussion

The results contained herein, while promising for supporters of medical marijuana, must also be weighed within the constraints of the population sample size. That said, future research involving larger population samples can now be obtained by utilizing our study methods to acquire data from all citizens that currently rely on medical marijuana in states where it is legal to obtain. 

The results contained in this anonymous study are a call to action to all institutions fearful of conducting this type of research within the confines and restrictions of their institutions. Such fear has ultimately retarded research. Such research dysfunction due to sociopolitical obstructions continue to disproportionally impact lower income communities. Moreover, prolonging the suffering being incurred by trusting patients of medical doctors that are routinely prescribing a myriad of medications to treat pain, depression and anxiety. Such medications that are currently legal to prescribe have resulted in an opiod and heroine epidemic that might argueably be halted via legal access and utilization of marijuana to treat similar, as well as a growing number of other symptoms. 

This study has been conducted on the heels of United States President, Donald Trump declaring an opioid crisis in America. Further, the President has implored those of us in the fields of medicine, mental health, research and social work to submit comments to the World Health Organization specific to marijuana's classification as a Schedule 1 drug.

Such steps will eventually result in political debates within the halls of the US Congress which will inevitably be delayed, tabled and put off at the cost of American lives, families and strain within our social service and prison systems. Such a realization should weigh heavily on the consciousness of our law makers. Their (US Congressional) delay on this matter is resulting in more deaths per year due to opioid overdoses than all of America's war dead since 1965. 

To reiterate, according to the CDC, Opioids were involved in 42,249 deaths in 2016 alone. To put this into truer perspective, the number of Opioid related deaths in America in 2016 is nearly six times greater than all of Americas war dead since September 11th, 2001 and nearly equal to all of our war dead from 1965 to present.

Meanwhile, research continues to compile studies such as this whereby marijuana appears to not only have medical value, but may very well be the plant that ends the opioid crisis. 

Recognizing that much more research is still to be done on this plant, it appears rather obvious that Marijuana is currently amongst the wrong classification of drugs and deserves to be rescheduled and researched in a more stable and clinical environment. Something that simply can not occur as it stands as a Schedule 1 drug. 

When the reclassification does occur, because it will, research will need to look at this plant in all of its many facets specific to genetic variances, Strains, concentrations, and ratios of each. Primarily, medical marijuana comes in an Indica, Sativa or Hybrid blend of both strains. Future studies should also  collect on these variables to ascertain outcomes for each to assist the medical community in addressing the question of dosage, timing and respective impact on symptoms as well as ratios of various plant components such as CBD:THC. 

 

REFERENCES and Additional Information

American Forces Press Service. (2013) United States Department of Defense. 18 January 2013. Archived from the original (PDF) on 16 January 2013. Retrieved 19 January 2013.

Beck A.T., Epstein N, Brown G, Steer RA (1988). "An inventory for measuring clinical anxiety: Psychometric properties". Journal of Consulting and Clinical Psychology. 56: 893–897. doi:10.1037/0022-006x.56.6.893.

Beck, A.T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571.

Beck, A.T., Steer, R.A., & Garbin, M.G. (1988). Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8(1), 77-100.

Edelen MO, Saliba D. (2010). Correspondence of verbal descriptor and numeric rating scales for pain intensity: an item response theory calibration.J Gerontol A Biol Sci Med Sci. 2010;65(7):778-85.

Groth-Marnat G. (1990). The handbook of psychological assessment (2nd ed.). New York: John Wiley & Sons.

Hedegaard H, Warner M, Miniño AM. (2016) Drug overdose deaths in the United States, 1999–2016. NCHS Data Brief, no 294. Hyattsville, MD: National Center for Health Statistics. 2017/ CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at http://wonder.cdc.gov

Hesselgard K, Larsson S, Romner B, Strömblad LG, Reinstrup P. (2007). Validity and reliability of the Behavioural Observational Pain Scale for postoperative pain measurement in children 1-7 years of age.Pediatr Crit Care Med. 2007;8(2):102-8.

Hockenberry MJ, Wilson D, Wilkenstein ML. Wong (2005). Essentials of Pediatric Nursing.7th ed.St Louis: Mosby.

Hojat, M., Shapurian, R., Mehrya, A.H., (1986). Psychometric properties of a Persian version of the short form of the Beck Depression Inventory for Iranian college students, Psychological Reports, 59(1), 331-338.

Leyfer, OT; Ruberg, JL; Woodruff-Borden, J (2006). "Examination of the utility of the Beck Anxiety Inventory and its factors as a screener for anxiety disorders". Journal of anxiety disorders. 20 (4): 444–58. doi:10.1016/j.janxdis.2005.05.004. PMID 16005177

Osman, A; Hoffman, J; Barrios, FX; Kopper, BA; Breitenstein, JL; Hahn, SK (2002). "Factor structure, reliability, and validity of the Beck Anxiety Inventory in adolescent psychiatric inpatients". Journal of clinical psychology. 58(4): 443–56. doi:10.1002/jclp.1154. PMID 11920696.

Steer, R. A., Rissmiller, D. J.& Beck, A.T., (2000). Use of the Beck Depression Inventory with depressed geriatric patients. Behaviour Research and Therapy, 38(3), 311-318.

Drug Schedules (https://www.dea.gov/druginfo/ds.shtml)

>> Alphabetical listing of Controlled Substances" (DEA)

Veteran Suicide Research Poll

Did you serve with a veteran that later committed suicide?
Yes - Please Continue to remaining questions
He/She had high PFT Scores
He/She had low PFT Scores
He/She had proficiency issues (Not to good at his/her job)
He/she had conduct issues (NJP, Court Marshal, OTH Discharge)
He/She had domestic challenged (Income, Debt, Marriage issues, Divorce)
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Need for Suicide Research

 CIR director discusses need for suicide research

CIR director discusses need for suicide research

Carl Castro, associate professor and director of the Center for Innovation and Research on Veterans & Military Families, participated in a suicide prevention podcast from the VA’s Rocky Mountain Mental Illness Research, Education and Clinical Center. In the 30-minute podcast, Castro discussed his work in this field, including a recent journal article outlining when a veteran might be more prone to suicide, a first step in more effective prevention efforts.

Article Reviews on Veterans Suicide

Daniel R. Gaita, MA

February 21st, 2017

Identification of Articles Importance

Recently released research by the herein reviewed 2016 Department of Veterans Affairs (VA) and 2015 Journal of American Medicine (JAMA) studies on veterans suicide include data sets of over 54 million veterans.  This new information now supersedes the previous 2012 VA Suicide Data Report. By converging the outcomes of each respective data set we appear to not only garner a greater understanding of the veteran population segment most likely to kill themselves, but may have also effectively pin-pointed the primary causes of and therefore solutions to the ongoing tragic suicides of nearly 20 US military veterans every day.

Overview of Articles

This work will examine three articles specific to the most recent research on veteran’s suicide. The first, Suicide Data Report (Kemp & Bossarte, 2012) is known as the study that brought awareness to the 22 veterans suicides a day. Second, Suicide Among Veterans and Other Americans (VA, 2016) relies upon a much larger data set. Third, Risk of Suicide Among US Military Service Members Following Operation Enduring Freedom or Operation Iraqi Freedom and Separation From the US Military (Reger, Smolenski, Skopp, Metzger-Abamukang, Kang, Bullman, Perdue, & Gahm, 2015) looks deeper into the sub categories of service members and suicide rates.

Article 1: Suicide Data Report, 2012

This study (Kemp & Bossarte, 2012) began in 2007 following a Mental Health staffing expansion through the Joshua Omvig Bill. It would also result in the development of data systems used to increase understanding of suicide among veterans in order to develop and improve suicide prevention programs. But for most of the US veteran Population it is known as the “22 A Day” study, which became a call to action at the VA and catalyzed veterans to look out for one another and to reach out for help.

The final report, with a cumulative price tag of $46,771.29 contains a systematic overview of data obtained from the State Mortality Project, Suicide Behavior Reports for fiscal years 2009-2012 and sought to determine the number of veteran deaths from suicide between 1999-2009. The end result was clean data from twenty-one states containing information on over 147,000 suicides. The data was then drilled-down to conclude that an estimated 22 veterans had died from suicide every day in 2010.

The study places emphasis on the significantly higher rate of male suicides. With the highest risk factor for veterans with an average age 54.5 years. 79% of suicides aged 18 or older were male and 44% of those suicides were among those aged 50 or older with 69% of all veteran suicides among those aged 50 years or older. Veterans that were married, separated or divorced had higher rates of suicide while those that were either widowed or single had the lowest rates. Veterans with a High School diploma or less represented 45% of suicides, while those with at least one year of college or more were far less likely.

Caution is advised not to make broad interpretations of the data based on proxy type reports of military history from only 21 states. Moreover, the study demonstrated wide variability across states with veteran suicides rates ranging from 7% to more than 26% of all suicides and warned that such findings prevent conclusions. Furthermore, the report articulates that it is a first attempt to formulate a comprehensive review; that it was not a research-based analysis and did have significant limitations specific to the data collected.

One detail of importance to note for future article analysis and discussion, is the study’s conclusion that the percentage of people who die by suicide in America that are veterans has decreased slightly from 2009-2012. This is a vital observation as the report then makes the inference that this finding provides preliminary evidence supporting the effectiveness of VA programs outcome specific to suicide prevention and mental health treatments. However, keep in mind that only those eligible to receive VA care are represented in that inference. This will be an important consideration as we review the next two articles.

 Article 2: Suicide Among Veterans and Other Americans 2001-2014

This joint Department of Defense & Department of Veterans Affairs, Office of Suicide Prevention analyses (VA, 2016 & Thompson 2016) is inclusive of over 55 million Veteran records from 1979 to 2014 from each of the 50 states in the nation. The data reduces the prior 2012 findings of 22 suicides per day down to an average of 20 Veterans a day in 2014. Of those, only 30% were utilizing VA services.

This is a vital observation, as it again calls into awareness that utilization of VA services is restricted to those eligible. Not all veterans are eligible for VA services. Those released dishonorably are not eligible for care, service or programs. In the next article we will identify how vital this observation may be in the future paradigm of veterans suicide prevention.

This 2016 VA report provides a brief summary of additional findings. Again, in this study we see that the highest rate, 65%, of all 2014 suicides were committed by those aged 50 years or older. Further, that the two highest VA utilizing groups to commit suicide have either a 50% or greater disability rating or are non-service connected and, non-compensable service-connected.

This is another key observation demonstrating that those who have the worst service-connected injuries are more likely to commit suicide along with those with injuries that are not eligible for any type of compensation. For the 50% and higher rated disabled I would contend it is a matter of suffering physically and or mentally regardless of economic compensation while for the non-service connected, non-compensable it may very well be a combination of both pain and suffering coupled with a lack of economic resources due to injury or disability, which often worsen with age.

In addition, this study also demonstrated a substantial increase in rates of suicide for younger veterans 18-29 and those aged 50-59. Also of interest to note, suicide rates of those aged 70-79 and 80+ represented the only veteran sub-groups with suicide rates lower than the civilian rate. However, an 85.2% increase since 2001 in suicide rates amongst the female veteran population was observed when compared to the 30.5% increase in the male veteran suicide rate since 2001.

The report highlights enhancements to the VA 24/7 crisis line, improved mental health services for females and the expansion of TeleMental Health Services. In addition, the report describes new free mobile applications deployed to help both veterans and their families while detailing the contributions of over 350 community and mobile based Vet Centers across all 50 states.

But again, while this report has shed light on who is committing suicide, little is provided to answer the question of why. For that answer we look at the next article.

Article 3: Risk of Suicide Among US Military Service Members Following Operation Enduring Freedom or Operation Iraqi Freedom and Separation From the US Military

This final article which appeared in the June 2015 Journal of the American Medical Association Psychiatry publication, (Reger, Smolenski & Skopp, et. al, 2015) may very well hold the proverbial key to unlocking the primary causes of veterans suicide while offering us a paradigm shifting insight on the solution to the problem.

The study sought to answer the question of whether or not deployment in support of Operation Enduring (OEF) or Iraqi Freedom (OIF) related to suicide risks. To do so they examined the records of all 3.9 million US military personnel between 2001- 2007 that served during either OEF or OIF, including suicides that occurred after separation. The main conclusion and finding was that Deployment was not associated with suicide but rather that separation status of a less than an honorable discharge, and serving less than 4 years was. Further study data also demonstrated that officers and senior enlisted members as well as those with more than 20 years in service had significantly far lower rates of suicide. In addition, those with a four year college degree or higher showed the lowest rate of suicide risk.

How does this tell us why veterans are killing themselves? To get to that answer we must next assimilate the meaning behind the data in these studies.

Article Summary and Analysis

Prior to the release of the data in the third article (Reger, Smolenski & Skopp, et. al, 2015), the standard paradigm for veterans’ suicide had connected Combat to Post Traumatic Stress (PTS) to suicide. Proof of such is measured in the enormous outlay of funds for these investigations and resultant implementation of evidence based treatments for PTS and Mental Health treatment leading up to the publication of the first study (Kemp and Bossarte, 2012) to present. Instead, what the convergence of article data suggest is the pathway for veterans’ suicide is connected as follows: Dishonorable or less than honorable Discharge –> Lack of access to available service -> (education, healthcare, compensation) –> Mental Health Crisis -> Suicide.

While the first two VA studies tell us who is committing suicide by way of age, gender and population demographics it is the third study, which concludes who is not. It is not due to deployment and thus not wholly due to combat. If it is not due to combat or deployment, how can it be attributed to combat PTS? It’s not, and here is why.

The third study data sets (Reger, Smolenski & Skopp, et. al, 2015) demonstrate that service members who serve less than four years and do not receive an honorable discharge have exponentially higher rates (3 or 4:1) of suicide than those serve at least four or more years and earn an honorable discharge. Service members with less than a year of service have the highest rate of suicide. Additionally, service members with an alternative high school diploma also have a 3:1 rate of suicide when compared to those with a four-year degree or higher. Thus the dilemma of veterans’ suicide is more a function of access to education and resources than a function of combat trauma.

This determination effectively flips the current paradigm of suicide prevention though mental health interventions on it’s head. In doing so it enables us to look at the real predictors and address them before a mental health crisis emerges.

To better understand, the reader must comprehend the culture of the armed forces specific to the Uniform Code of Military Justice as it pertains to how veterans are separated from service and further understand how various separation codes (Honorable, Less Than Honorable, Bad Conduct, Dishonorable etc) impact post service eligibility to VA programs and services.

If a veteran serves less than four years, it is most likely due to some form of administrative or other than honorable discharge determination. As a result the separated service member may not eligible for many programs that include but are not limited to VA Disability Compensation, Education and Healthcare benefits. Looking back at the first two studies, it was observed that veterans that did not use the VA Healthcare System committed 70% of veteran’s suicides. Perhaps lack of eligibility due to less than honorable discharge is a culprit? It is certainly worth further investigation. That is the first argument.

The second is based on educational attainment. The next highest risk group for veterans suicide in the third study was veterans with no high school or an alternative diploma. While the lowest rate of risk of veterans suicide was observed by those with a 4-year degree or higher, and again confirmed by the observation that Officers made up the group with the lowest risk for suicide. In order to be an officer you must have a four-year degree.  

Lack of access to post service education benefits or vocational rehabilitation opportunities due to separation and discharge status determination may be a primary factor and precursor to the later mental health challenges that result in suicide. It is certainly worth further investigation.  

Deductive reasoning lends us to better understanding of the actual simplicity of the problem of veterans suicide which, when observed through the convergence of these data sets can be summed up in these eight words: Get an Honorable Discharge and a College Degree.

 Implications of Analysis

With the convergence of data from these three reports it appears possible the current paradigm of federal funding targeting towards stopping veterans suicides may be misdirected towards the treatment of PTSD and Mental Health interventions. This is in no way meant to diminish the value of the work being conducted in the fields of Mental Health, as they are essential and the data supports the efficacy of that work. But rather as a means to enable further consideration of other possible root causes of suicide that may better be addressed through improved Officer and Staff Non-Commissioned Officer leadership training in order to help correct the behavioral deficits that may be the primary cause of early separations from the armed forces as a result of avoidable behavioral and disciplinary outcomes.

Perhaps less emphasis on non-judicial and court martial proceedings and more emphasis on behavioral modification strategies that many in the Armed Forces leadership ranks have argued have been recently replaced due to shifting political and social ideologies. This is not to diminish the effectiveness of military type leadership, but rather re-embolden it to again be effective at ensuring mission readiness through discipline and purpose. While at the same time evolving it through a deeper understanding of human psychology via evidence-based interventions at the Department of Defense level. This type of effort has the capability to shape a potential suicide candidate into a respectable member of the armed forces worthy of the programs, service and benefits that come with an honorable discharge. Such programs and services, the data shows, are associated with far lower risk of suicide.

References:

Kemp, J., & Bossarte, R. (2012) Suicide Data Report, 2012. Department of Veterans Affairs, Mental Health Services, Suicide Prevention Program. Retrieved from http://www.va.gov/opa/docs/suicide-data-report-2012-final.pdfReger, M.A., Smolenski, D. J., 

Skopp, N. A., Metzger-Abamukang, M. J., Kang, H. K., Bullman, T. A., Perdue, S., & Gahm, G. A. (2015) Risk of Suicide Among US Military Service Members Following Operation Enduring Freedom or Operation Iraqi Freedom Deployment and Separation From the US Military. JAMA Psychiatry. 2015; 72(6):561-569. doi:10.1001/jamapsychiatry.2014.3195 Published online April 1, 2015.

Thompson, C. (2016) VA Suicide Prevention: Facts about Veterans Suicides. Suicide Prevention and Community Engagement. Retrieved from http://www.va.gov/opa/publications/factsheets/Suicide_Prevention_FactSheet_New_VA_Stats_070616_1400.pdf

VA (2016) VA Office of Suicide Prevention. Suicide Among Veterans and Other Americans. US Department of Veterans Affairs, Washington, DC. Available online: http://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf

 

EMDR and Information Processing in Psychotherapy Treatment

By: Daniel R. Gaita, MA

 Summary

Originally designed to treat traumatic memories, Eye Movement Desensitization and Repossessing (EMDR) has demonstrated efficacy in the treatment of Post Traumatic Stress Disorder (PTSD) (Van der Kolk, 2003). While its name has created confusion, this article directs the reader to rather think of EMDR as simply, reprocessing therapy, or in keeping with the acronym EMDR, Emotional and Mental Development and Reorganization. More specifically, EMDR is a modern and integrative approach, which implements eight phases of procedures and protocols, synthesizing elements of cognitive, behavioral, psychodynamic, person-centered, and body-based therapy.

By utilizing the Adaptive Information Processing model (AIP), which states that memory is associated, thus learning occurs through the creation of new associations, EMDR allows one to address dysfunctional experiences or traumas by changing their associations and thus reprocessing the memory to result in more adaptive outcomes (reduction of symptoms).

The goal of EMDR is to target and connect unprocessed traumatic memories to the more adaptive information located in other memory networks by associating the traumatic memories with existing adaptive information. The result is a reduction in symptoms as related to image, thought, affect, and body sensation.

Eight-Phase Approach

History-taking, evaluation and treatment planning. This phase is similar to standard psychotherapy but also identifies key life events for further targeting and processing as well as present situations, which cause distresses that interfere with adaptive functioning.

Preparation. Next the client is educated about symptoms and treatment expectations.

Processing. Phases three-through six involve processing distressing memories, present triggers or future templates so as to mobilize the information and facilitate connections with other adaptive information.

Closure. Represents an evaluation of adequacy of processing along with self-calming interventions from phase two. Additionally, the client monitors intersession responses using a log.

Reevaluation. Whereby evaluation of previous work is conducted at the beginning of each session. Treatments successes are assessed and further coping strategies are utilized.

Response

Having been working as an advocate for combat veterans since 2012, and also having a diagnosis of PTSD, I was most inspired by the realization that EMDR enables the clients to evolve from the symptoms of trauma and actually turn those traumas into fruitful, useful and purposeful experience’s that serve to help others.  Many of us in the combat veteran community are now referring to such biopsychosocial evolution as Post Traumatic Growth (PTG). EMDR appears to be an effective gateway towards that end.

 Reference

Mattis, J.M. (2017) Mattis on PTSD and PTG Post Traumatic Growth. Youtube. Retrieved from https://www.youtube.com/watch?v=89s4fqJAepM

Van der Kolk, B. (2002). EMDR and information processing in psychotherapy treatment. In M. Solomon & D. Siegel (Eds.), Healing trauma (pp. 168–195). New York, NY: Guilford Press.

Van der Kolk, B. (2003). EMDR and information processing in psychotherapy treatment: Personal Development and Global Implications. In M. Solomon & D. Siegel (Eds.), Healing trauma (pp. 196–220). New York, NY: W.W. Norton & Co.

 

A Clinical Model for the Comprehensive Treatment of Trauma Using an AffectExperiencing-Attachment Theory Approach

Summary

Amazingly, this reading reiterates the substantial and long-term effects of insecure attachments, both intergenerational and during our early life neurologic development. Delving deeper into the consequences of parental neglect and abuse (in it’s many forms) we are made aware of their impact on our ability, or lack thereof, to transcend the dilemmas of various forms of trauma. Whether they are large acute traumas such as September 11th, 2001 or the steady drip of fear, helplessness, abandonment, shame and humiliation experienced during our early life.

What we now know, is that improper or dysfunctional attachment early in life leads to a multiplier effect in the probability of our development of behavioral, social, biologic and cognitive disorders, and tendency towards neuroticism such that our conscious capability to digest trauma is retarded and maladaptive,

Conversely, successful early life attachment results in a healthy and sustained ability to adapt to various traumas. Furthermore, that effective, and in many cases, short term dynamic psychotherapeutic treatment can enable corrections of such attachment deficits by reconnecting the conscious mind of the present to the unconscious pain and emotions from the past.

Response

This was both, a fascinating and reinforcing view of attachment theory and the intergenerational epigenetics of trauma and abuse. Coupled with a descriptive six hour attachment-based psychotherapy tool which highlights the precise techniques used to unlock the unconscious such that healing can begin through greater understanding of self and how our feelings work to either entangle or untangle our dilemmas through greater coping skills.

 

Reference

Neborsky, R. (2002). A clinical model for the comprehensive treatment of trauma using an affect experiencing-attachment theory approach. In M. Solomon & D. Siegel (Eds.), Healing trauma (pp. 282–321). New York, NY: Guilford Press.

Combat Does Not Cause Suicide - Bad Discharges Do

FROM:

Operation Vet Fit

TO:

Honorable Barack Obama

President of the United States

1600 Pennsylvania Ave NW

Washington, DC 20500

&

Honorable Donald J. Trump

President-elect of the United States

1600 Pennsylvania Ave NW

Washington, DC 20500

SUBJECT: VETERAN SUICIDE - CAUSE AND SOLUTION

Dear Mr. President and Mr. President-elect:

Our agency has recently converged data furnished by the Journal of the American Medical Association (Reger, Smolenski, Skopp et. al., 2015) and the US Department of Veterans Affairs (VA, 2016 & Thompson, 2016), which appear to show the key causes of veteran suicide is not war, not post traumatic stress disorder, and not the quality of care received at the Veterans Affairs Medical Centers, but rather lack of access to VA services and post service educational benefits as a direct result of improper Department of Defense administration practices which led to veterans’ statuses of discharges of “less than honorable”, which result in ineligibility for these vital programs and services. 

As a direct result of this recent convergence of information I write to echo the urgent request of the Vietnam Veterans of America, High Ground Veterans Advocacy, Fairness for Veterans and the broad bipartisan network of Congressional leaders to put an end to the social plague of veteran suicide through the use of the power vested in the office of the President.

Doing so now will help the most vulnerable veterans in our country by pardoning all Post-9/11 veterans with PTSD who were administratively separated, resulting in a less-than-honorable discharge without the due process of a court-martial; and to request that President-elect Trump commit the full support of his incoming administration for this executive action. Every day delayed, twenty veterans kill themselves.

The summary of findings and conclusions are based on the two studies (Reger et al., 2015; Thompson, 2016 & VA, 2016), which incorporate the data of over 50 million veteran records in one study and nearly 4 million in the other.  The convergence of the findings of these two studies demonstrate that the highest suicide risk population of veterans are those that have served less than four years, that were discharged under less than honorable conditions, that have not enrolled in VA services and have not attained a four year college education or higher.

In short, the cause and solution to the dilemma of veteran suicide lay squarely in the wrongful determination of the character of a veteran’s service to his or her country. Many times this is the direct result of behavioral outcomes associated with undiagnosed combat PTSD and at other times it is the result of a non-judicial system of governance that fails to effectively weigh the long-term outcome of poorly crafted administrative decisions that fall outside of the scope of proper due process (Goldsmith, 2016).

 

Respectfully Submitted,

Daniel R. Gaita, MA

Veteran, United States Marine Corps

Founder & Director, Operation Vet Fit

University of Southern California Graduate Student,

Clinical Masters in Social Work, Military Families

 

Cited Sources

Goldsmith, K.S., Russel, J. (2016) Resorting Honor to Veterans with Invisible Injuries. High Ground for Vets. Available online: https://www.highgroundvets.org/fairness4vets

Reger, M.A., Smolenski, D. J.,  Skopp, N. A., Metzger-Abamukang, M. J., Kang, H. K., Bullman, T. A., Perdue, S., & Gahm, G. A. (2015) Risk of Suicide Among US Military Service Members Following Operation Enduring Freedom or Operation Iraqi Freedom Deployment and Separation From the US Military. JAMA Psychiatry. 2015; 72(6):561-569. doi:10.1001/jamapsychiatry.2014.3195 Published online April 1, 2015.

Thompson (2016) VA Suicide Prevention Program Facts about Veteran Suicide July 2016 Available online: http://www.va.gov/opa/publications/factsheets/Suicide_Prevention_FactSheet_New_VA_Stats_070616_1400.pdf

VA (2016) VA Office of Suicide Prevention. Suicide Among Veterans and Other Americans. US Department of Veterans Affairs, Washington, DC. Available online: http://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf

Suicide Prevention Group Therapy Model

Bridge the Gap - Group Therapy Model for Combat Veteran Suicide Prevention

Daniel R. Gaita, MA

October 24th, 2016

Bridging the Gap

Since the recent United States led wars in response to the attacks of September 11th, 2001, American veteran suicides have taken a front and center position on the stage of mental health treatment studies. Veterans Affairs and Department of Defense studies have placed the veterans’ suicide rate between twenty and twenty-two per day (Kemp & Bossarte, 2012; Thompson, 2016). Multitudes of data have been collected across dozens of studies determining the most effective evidence based treatment strategies for Post Traumatic Stress Disorder (Amos, Stein, & Ipser, 2014; Bisson, Roberts, Andrew, Cooper, & Lewis, 2013; Cahill & Foa, 2007; Chard, Resick, Monson, & Kattar, 2009; Dworkin, 2011; IOM, 2008; Monson, Schnurr, Resick, Friedman, Young-Xu, Y & Stevens, 2006) which often accompanies other comorbid symptoms such as depression and substance use disorders which too can lead to suicide (APA, 2013; Kuehn, 2008; Roberts, Roberts, Jones, & Bisson, 2016). While manuals for public access have been produced which provide detailed instructions on implementing trauma focused cognitive processing therapies, session by session (Resick, Monson, Galovski, Chard, & Kattar, 2010), what is missing is more work towards actually getting more veterans interested in seeking treatment in the first place. This “gap” between those needing and seeking mental health services is the focus of our group. This paper will discuss precisely why veterans tend to avoid treatment, how to “bridge the gap” and engage them in the discussion of available modalities, and also provide a template group therapy outline to enable greater engagement by veterans prior to the creeping ideations of suicide that often preempt such self-inflicted and avoidable tragedies.

 Analysis of the Gap – Creating the Group Population

The “Gap”, is the term used herein to identify the apparent disconnects between effective evidence based interventions being utilized and those combat veterans that are reluctant, ambivalent, and/or resistant towards their use and implementation. The specific group served will be open only to United States Armed Forces combat veterans. Members will be chosen based on proof of combat service as provided through submission of their Certificate of Discharge, Department of Defense Form DD-214.

Statistics

Veterans that did not use VA mental health services carried out 70% of the reported veterans suicides with 65% of all veteran suicides carried out by those 50 years of age or older (Thompson, 2016). This is of major importance when working to determine more effective engagement strategies that will get veterans to utilize the evidence based interventions that are showing promise through the various Veterans Affairs clinics and affiliated agencies. This is the gap that we must bridge.

Background and Rationale

Veterans that have served in the United States Armed Forces, in combat, were trained to kill the enemy. They are disciplined and effective towards that objective. Weakness in any form or facet of existence is simply not an option for those tasked with killing our enemies. As a result, three elements impact human behavior: Internal Bias, Transference and Cognitive Dissonance, all of which permeate the psyche of a combat veteran, are discussed in greater detail below due to their respective and extraordinary influence over the perceptions veterans hold specific to mental health treatment in the first place. Especially for those whom experienced combat, these veterans were exposed to traumatic events resulting in the taking of the lives of others or having had to watch others being killed. For these men and women, weakness, as perceived in any form is utterly out of the question; thus where the gap emerges. This is the rationale behind the group population selection.

Internal Bias

Internal Bias represents our unconscious and conscious tendency, trend, inclination, and feelings which are often times unreasoned opinions and prejudices about other social groups or individuals based on our life experiences and environments (Robbins, Chatterjee & Canda, 2011). Given this definition, it is then understandable that combat veterans would have a drastically different internal bias toward mental health treatment than their civilian counterparts. Since it requires the combat veteran to conceive that he or she has a weakness or disorder; such a concept is in absolute contradiction to the established “norms” of the warrior mentality.

Transference

Transference represents our unconscious tendency to project onto others both attitudes and feelings that were significant early on in life (Robbins et al., 2011). In many cases this can be of feelings endured as a child with parents or even later on in life through traumatic episodes such as combat. With weakness often times comes death in the combat theatre. Thus strength is not just an essential component of ones identity, but moreover a basic requirement for survival.

Cognitive Dissonance

Cognitive Dissonance refers to our own internal attitudes and beliefs or behaviors, which are conflicted when we are exposed to other beliefs that are inconsistent with our own. This, often times, results in irrational and sometimes maladaptive behavior due to an internal clash, which creates unpleasant tension (Festinger, 1957).  When a combat veteran that has survived by the laws of strength and discipline is confronted with the concept of needing mental health interventions resulting from combat action it creates exactly the type of cognitive dissonance that results in tension and in many cases, maladaptive behavior.

Stigma

The question then remains, how do we shift the perception that can translate enrollment into mental health services from having the attached stigma of weakness, to instead be perceived as a sign as a of great strength. So that the most effected will see themselves as warriors continuing to do battle against a common enemy, rather than proverbial “pussies” that “Can’t handle life”?

Bridging the Gap With Solution Focused Therapy

Reaching out to veterans that do not believe they are amongst the population in need of interventions is precisely how we bridge the gap. This type of effort requires community relationships between the social worker, veteran’s agencies and service organizations.  It means tapping into the veteran population that weighs least on the VA system, through local Veterans Tax Benefits Coordinators and Tax Assessors whom know the local veterans population that have withdrawn from the ranks, that tend to live out their days in solitude with a withering sense of life purpose.

We create interest in this group by changing the veterans’ perceptions towards opening oneself up to the possibilities of a brighter future, a better mid-life chapter post combat. It is done by not calling it therapy, but rather camaraderie, while providing these men and women with an opportunity toward purpose rather than treatment. Thus it is modeled after Solution Focused Brief Therapy (SFBT), which is both goal and future oriented, and collaborative (Trepper, 2012).

The basis and rationale of this course of action is not reflective of evidence on its efficacy for this specific population sub group, but rather lack thereof and thru the personal observation of the writer, who is also a combat veteran and who founded a non-profit agency specifically to address the issue of both PTSD and Veteran suicide. SFBT has been left out of most of the recently cited comparison studies and Meta analysis on the treatment of PTSD and its comorbid symptoms (Dworkin, 2011).  Yet SFBT has been widely accepted as a best practice for substance abuse (Berg and Miller, 1992) and Depression (Spilsbury, 2012), which are both common comorbid symptoms that accompany PTSD (APA, 2013) and common amongst those who have committed suicide.

Bridge the Gap - The Curriculum

This group will meet weekly for 10 weeks; each meeting will be for one hour and the therapist will be available for up to thirty minutes following each meeting for any needed specific discussion with any group individual.

 Week 1: Brotherhood

Terminal Objective: Initial Evaluation and Establishment of Rapport

At a predetermined location (Town hall meeting room, local gym, coffee shop, campfire, BBQ, VFW or American Legion Hall, etc.), our group of 3-10 combat veterans will gather. This first meeting is about gathering our initial evaluation data, establishing rapport and ensuring the privacy and confidentiality of the group.

To do so, we will be seeking information on the number of services the veteran has used since end of enlistment based on personal recall. Simultaneously, the veterans will be rekindling a lost sense of brotherhood amongst the members based on the following rationale.

With shared suffering, hardships and adversity comes lessons in resiliency. One common link that bonds all combat veterans together is that of combat experience. They (combat veterans) have, regardless of branch of service, age or gender a bond that when in common company, emerges a set of conversations that take on a life of their own. Often profane, barbaric, and geared toward inhumane humor, which serve as coping mechanisms that give them light in places that may have long since gone dark.

Enabling Objective: Baseline Measurements & Rekindle Sense of Brotherhood

The therapist hands out a short confidential questionnaire (Appendix A), asking the veteran to list any veteran’s agencies, groups, or services they have used since re-entering the civilian sector. While collecting the questionnaire, the therapist works to encourage dialogue through complimentary and positive observations of shared stories of service, branches served, specific occupations, years of service and by helping each member identify and acknowledge what has been working since becoming a civilian. 

 Week 2: Camaraderie

Terminal Objective: Building a Group History

This week we will build off of our first introductions and discuss service successes and proud moments as well as others that combat veterans tend to look back at and laugh. This meeting concept is based on the following rationale.

You can take a 100-year-old WWII Veteran, a 70-year-old Vietnam veteran, a 50-year-old Gulf-War veteran and a 23-year-old OIF/OEF veteran, who all share combat service and put them into a room together. Within five minutes of meeting each other, the titles, genders, ages and net-worth of each will be shed off, their current places in society will be erased and all that will matter is the sharing of their service and respective stories or remembrance of events which they each have at least one thing in common, combat. It is surreal to behold, but powerful and useful if harnessed effectively.

Enabling Objective: Rekindle sense of brotherhood

The therapist works to focus on the collective good achieved by the group by building a medals and ribbons bar that reflects the combined service and sacrifice of all the group members. This will serve as a graphic depiction of every award and medal earned by all members of the group, which serves as a powerful, and visual motivational tool for future sessions geared toward the future goals of both purpose and service.

 Week 3: Introduction to Purpose

Terminal Objective: Exposition of Resources

This week we will discuss the element of individual purpose while the therapist subtly exposes the members to available resources. This is done through open discussions of members on the topic of purpose, when they may have lost it and how they can get it back by sharing collective positive examples of their most motivating purposes in their life. For many, it will be a reflection of their time in combat.

The rationale for this type of subtle introduction of available resources is grounded in the common observation that this group of combat veterans has not sought help or assistance and may feel ambivalent about it. Therefore the therapist only interjects the availability of a resource when a particular purpose based topic underscores its need.

Enabling Objective: Handout Provided With Resource Listing

While presenting the groups combined ribbons bar (Appendix B), the therapist works to focus on the positive aspects of the members’ recollections of prior or current purpose driven accomplishments, while exposing the entire group to the litany of available resources geared toward making more such purpose driven activities and events possible. Every member receives a complete listing all available resources with websites, contact numbers and brief descriptions of what each is for.

 Week 4: Community Needs Assessment

Terminal Objective: Stoking the Flames of Purpose

This week the group will discuss ideas to help the local community.  Food drive, toy collection, collaboration with area veterans agencies, feed the poor, drive a vet, Santa’s workshop, fix a house, etc. The group will determine the activity(s) and its purpose(s).

Enabling Objective: Building a Group “Mission”

The therapist works to focus on the abilities of the group to serve the greater good of the local community while understanding it serves the participant combat veterans sense of purpose too. Therapist will then work with the group to coordinate collaborative meetings with local agency officials to iron out logistical details of group mission and community needs.

 Week 5: Mission Logistics

Terminal Objective: Enhancement of resource understanding

The therapist works to continue acknowledgement of group work toward purpose while going into greater detail of various modalities being used to assist our other veterans. Conversations on PTSD and SUD may arise and opportunities to introduce concepts may come up throughout planning phases of event.

Enabling Objective: Dates, Times and Places of Community Event

This week we will discuss the logistics of our community based event. Here we will coordinate the event place, time and date to be used for future collaboration and promotion within the community and towards the accomplishment of the purpose driven mission.

The therapist works to focus on the positive aspects of the group’s weekly achievements and contributions while also seeking to locate areas where group members may be demonstrating a specific need or openness toward other interventions or services.

 Week 6: Vet Center Introduction

Terminal Objective: Expose Group Members to Area Vet-Center Staff

During this session, the therapist will introduce a special guest, whom is also a combat veteran and director of the area VA Veterans Center. The focus will be on the Vet Center’s interest in the good the group is preparing to do in their upcoming community project while simultaneously fostering a sense of symbiotic collaboration and partnership with the group and its members. 

Enabling Objective: Pin Point of Contact For Mezzo Options

Here, the therapist guides the engagement of members with the point of contact at the local community Veterans Center. It is at this point that each member is provided Vet Center brochures and contact cards that they can choose to either use for them or provide to another veteran that may be in need.

 Week 7: VA Veterans Service Officer Introduction

Terminal Objective: Expose Group Members to local Veterans Affairs Service Officer

During this session, the therapist will introduce another special guest. This week’s guest will be an area Department of Veterans Affairs Service Officer that specializes in assisting veterans in obtaining valuable services, many of which are often unknown by veterans that have not used the VA since entering the civilian sector. 

Here, the therapist guides the engagement of members with the point of contact at the VA. It is at this point that each member is provided valuable information on available VA programs and services that may have peaked an interest during last week’s Vet Center meeting. Again, brochures and contact cards will be provided that they can choose to either use for them or provide to another veteran that may be in need.

Enabling Objective:  Expanding Knowledge of Macro Options

The focus will be on the Service Officer’s interest in the good the group is preparing to do in their upcoming camaraderie building, community based project while simultaneously fostering a sense of symbiotic collaboration and partnership with the group and its members.  It also serves to add redundancy and layered depth to the previous weeks content.

 Week 8: Introduction to Mobile Applications

Terminal Objective: Expose Group Members to Electronic Mobile Applications for Self Help

During this session, the therapist will guide discussion around the benefits of self-help applications that can be downloaded onto mobile devices.

Enabling Objective:  Expanding Knowledge of Mobile and Micro Options

The therapist will briefly discuss multiple downloadable and free mobile applications that can either be used or shared with their fellow veterans. We are arming them with the knowledge of available treatment modalities without attempting to force their use.  If they have an interest in any of these applications, or modalities they will now be able to peruse them in private. The following applications will be introduced:

PTSD Coach. This is a downloadable Veterans Affairs and Department of Defense project. It serves as a tool for self-management of PTSD, and includes: a self-assessment tool, educational materials about PTSD symptoms, related conditions, treatments, relaxation and meditation exercises, crisis resources, personal support, and professional mental healthcare contacts. It was released in 2013 and has been downloaded 86,000 times in 87 countries. (Thompson, 2016).

ACT Coach.  Another downloadable application specifically targeted for depression that was released in 2014 and has been downloaded 23,000 times in 93 countries. It works in conjunction with Acceptance and Commitment Therapy (ACT) in an effort to bring the practice into daily life (Thompson, 2016).

Mindfulness Coach. Another mobile tool to assist users in practicing mindfulness meditation. This application was released in 2014 and has been downloaded 39,000 times throughout 95 countries (Thompson, 2016).

Moving Forward. Another 2014 released application that teaches problem solving skills. It can be used by itself or in conjunction with participation in Problem Solving training. It has already been downloaded 5,400 times in 54 countries (Thompson, 2016)

Week 9: Community Project

Terminal Objective: Engage Members in Purpose Driven Activity

During this session, the therapist will guide discussion around the actual event. How it feels to help, to serve a purpose, and expand upon the natural happening of the camaraderie based community event. Whether it is a food drive, community clean up project; or a clothing or toy collection for needy children, the group members will feel a renewed sense of purpose and achievement. The therapist merely serves to point out observations of successes and accomplishments throughout the event.

Enabling Objective:  Doing Good for Others in the Community

Through their own action and participation in their coordinated community event, the group members will exhibit a renewed sense of self worth, purpose, and identity. For some, this will be a feeling that has been absent for years or perhaps decades.

As can be observed by those that have left a motivational seminar, the group members will be eager to share their experiences with others that may not be aware such a group program ever existed. They will be expanding community awareness of the program while fostering the brotherhood and camaraderie they knew they missed and are now aware still exists but now it is in a much more healthy and far different environment.

 Week 10: Outcome Evaluation and Future Consideration

Terminal Objective: Measure Outcome

During this session, the therapist will reflect back upon the previous week’s accomplishments through dialogue and discussion of the event, and gather participant feedback and guidance specific to future collaborations.

Enabling Objective:  Individual Questionnaire

Participants will be handed the same questionnaire they completed in week one. The objective is to measure week one answers with week ten answers to learn if the group curriculum has resulted in a bridging of the gap between available services and utilization of services by the group participants.

An increase in participation rates amongst group members demonstrates that the purpose of the group, “Bridging the Gap”, has been served. Knowing that veterans whom participate in the available programs and services provided through the VA and other affiliated agencies are less likely to commit suicide should result in an overall reduction in both suicidal ideation, depression rates and suicides amongst group participants.

Appendix A

Combat Veteran Questionnaire of Utilized Services

Please do not put your name on this questionnaire

Dear fellow Combat Veteran,

Thank you for taking your time to participate in this group. All participating members here today have served in the combat theatre and represent multiple branches of the United States Armed Forces that have served during different combat operations. Each participating members combat action has been verified via submission of their respective DD-214’s.

Confidentiality

Please note that this is a private and closed group. Everything we share is confidential. No personal identifying information or other personal information shared herein will be shared with any other individuals or agencies with the following exceptions: written permission from client to share information; and second, unless release of identifying information is determined to be necessary to prevent harm to yourself or others, as we are mandated by law to report such instances.

Initial Services Questionnaire

On the attached blank page, please list any veteran’s services that you have used or currently use since your discharge or retirement from the Armed Forces. Feel free to share any non-veteran related services that you may have used too. Such services may include but are not limited to: Health and fitness related products or services, mental health services, nutritional services, disability services etc.

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Amos T, Stein D.J., Ipser J.C. (2014). Pharmacological interventions for preventing post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2014, Issue 7. Art. No.: CD006239. DOI: 10.1002/14651858.CD006239.pub2. Retrieved from: http://www.cochrane.org/CD002795/DEPRESSN_medication-post-traumatic-stress-disorder.

Berg, I.K. and Miller, S. 1992. Working with the problem drinker: A solution-focused approach, New York, NY: W.W. Norton.

Bisson J.I., Roberts N.P., Andrew M., Cooper R., & Lewis C., (2013) Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Retrieved from: http://www.cochrane.org/CD003388/DEPRESSN_psychological-therapies-chronic-post-traumatic-stress-disorder-ptsd-adults

Cahill, S. P. & Foa, E. B. (2007). PTSD: Treatment efficacy and future directions. Psychiatric Times, 24(3), 32 – 34.

Chard, K. M., Resick, P.A., Monson, C.M., & Kattar, K. (2009). Cognitive Processing Therapy: Group Manual. Veterans Administration

Dworkin, D. (2011). A critical review of psychosocial interventions for veterans with posttraumatic stress disorder. Retrieved from http://libproxy.usc.edu/login?url=http://search.proquest.com.libproxy2.usc.edu/docview/866298062?accountid=14749

Festinger, L. (1957). Cognitive dissonance theory. 1989) Primary Prevention of HIV/AIDS: Psychological Approaches. Newbury Park, California, Sage Publications.

Institute of Medicine (IOM). (2008). Treatment of post-traumatic stress disorder: An assessment of the evidence. Washington, D. C.: The National Academies Press.

Kemp, J., & Bossarte, R. (2012) Suicide Data Report, 2012. Department of Veterans Affairs, Mental Health Services, Suicide Prevention Program. Retrieved from http://www.va.gov/opa/docs/suicide-data-report-2012-final.pdf

Kuehn, B. M. (2008).  Scientists probe PTSD effects, treatments. Journal of the American Medical Association (JAMA), 299(1), 23 – 26.

Monson, C. M., Schnurr, P. S., Resick, P. A., Friedman, M. J., & Young-Xu, Y., & Stevens, S. (2006). Cognitive Processing Therapy for Veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 1074, 898-908.

Resick, P.A., Monson, C.M., & Chard, K. M. (2008). Cognitive Processing Therapy: Veteran/Military Manual. Veterans Administration. Retrieved from: http://alrest.org/pdf/CPT_Manual_-_Modified_for_PRRP(2).pdf

Resick, P.A., Monson, C. M., Galovski, T. E., Chard, K.M. & Kattar, K. A. (2010). Cognitive Processing Therapy: Veteran Military Consultants Manual. Veteran's Administration

Roberts N.P., Roberts P.A., Jones N., Bisson J.I. (2016) Psychological therapies for post-traumatic stress disorder and comorbid substance use disorder. Cochrane Database of Systematic Reviews 2016, Issue 4.

Robbins, S. P., Chatterjee, P., & Canda, E. R. (2011). Systems theory. In Contemporary human behavior theory: A critical perspective for social work (3rd ed). Boston, MA: Allyn & Bacon.

Spilsbury, G. 2012. Solution-focused brief therapy for depression and alcohol dependence: A case study. Clinical Case Studies., doi:10.1177/1534650112450506

Thompson, C. (2016) VA Suicide Prevention: Facts about Veterans Suicides. Suicide Prevention and Community Engagement. Retrieved from http://www.va.gov/opa/publications/factsheets/Suicide_Prevention_FactSheet_New_VA_Stats_070616_1400.pdf

Trepper, T. S., (2012) Solution-Focused brief therapy with Families Asia Pacific Journal Of Counseling And Psychotherapy Vol. 3:2.

 

Analysis of PTSD Treatments

Article Review on Effective Strategies in the Treatment of Post Traumatic Stress Disorder

Daniel R. Gaita, MA

September 15th, 2016

Effective Treatment For PTSD

 

Identification of Article Importance

 

This paper covers a critical review (Dworkin, 2011), of seventeen published studies specific to psychosocial interventions between 2000-2010 for veterans with Post Traumatic Stress Disorder (PTSD)

Specialty Population Served

The article we have selected for this work is a focused critical review of the psychosocial interventions currently being administered for veterans with PTSD.

Explanation of Chosen Treatment

We have chosen Cognitive Processing Therapy due to repeated efficacy in findings using data collected from the Clinician Administered PTSD Scale (CAPS) across multiple studies referred to in the Dworkin, 2011 article and in addition to supportive data in its use in group and video teleconferencing group settings. (Morland, Hynes, Mackintosh, Resick, & Chard, 2011).

Measuring PTSD symptoms with CAPS.

Clinician Administered PTSD Scale (CAPS). The CAPS is a 30-item scale that measures the existence and intensity of the 17 symptoms of PTSD as stated in the DSM- IV (Blake et al., 1995). The CAPS is completed by way of a mental health professional interviewing a subject with the use of the scale (Blake et al., 1995). Severity scores of 0-19 = asymptomatic/few symptoms, 20-39 = mild PTSD/sub threshold, 40-59 = moderate PTSD/threshold, 60-79 = severe PTSD symptomatology, and > 80 = extreme PTSD symptomatology," (Weathers, Keane, & Davidson, 2001, p. 135). Change in scores representing a decrease or increase in CAPS scores ranging from 10 to 15 have been recommended or used as interpretations of clinical significance (Weathers et al, 2001; Ready, Thomas, Worley, Backscheider, Harvey, Baltzell, & Rothbaum, 2008).

Evaluation of findings.

Following an evaluation of clinician administered PTSD Scale (CAPS) scores, pre and post treatment, specific to their utilization in data collection for Cognitive Processing Theory (CPT), Exposure Therapy, Present Centered Therapy, Skill Building focused CBT and Multimodal Therapy, the extensive review of psychosocial interventions provided in the Dworkin, 2011 analysis demonstrate greater short and long term efficacy in treating PTSD with the use of Cognitive Processing Therapy (CPT) and exposure-like therapies.

 Article Summary and Analysis

How Techniques Apply

CPT focuses on creating a detailed account of one's trauma in order to alter maladaptive accommodations and assimilations by reconstructing them in more adaptive ways for the individual, which is theorized to allow a person to confront and reduce symptoms acquired from trauma (Sobel et al., 2009).

Description of Therapeutic Application

CPT is a recovery-focused therapy, which works off both collaboration and informed choice, uses a twelve-session protocol implemented either individually, in-group, or both and may or may not include trauma focused cognitive therapy. However, it can be implemented without traumatic accounts (Resick, Monson, & Chard, 2008).

Critical Analysis

The results of CPT for both Vietnam and Operation Iraqi Freedom and Enduring Freedom (OIF/OEF) veterans showed no significant differences between groups but did demonstrate treatment efficacy across both populations with CAPS score of 71.88 reduced to 31.50 for OIF/OEF and 66.48 reduced to 42.50 for Vietnam Veterans. Similar findings of overall CAPS score reductions were replicated across multiple studies (Dworkin, 2011).

Key Finding for Future Research

Of importance to note is the rapid increase in suicide rates among female U.S. Veterans by the Department of Veterans Affairs (Thompson, 2016), yet very little data is presented across all 17 published studies cited in the Dworkin review of psychosocial interventions on female study subjects.  While CPT had been initially conducted with rape victims and has since been used successfully with a range of other traumatic events (Resick, Monson, & Chard, 2008) we will need more research as it applies to women in the armed forces as they take up a growing number of newly opened positions in the combat arms sectors. Effective treatment interventions for combat trauma will be instrumental in ensuring the long-term mental health of female veterans equally to their male counterparts.

Application to Selected Population

Today, CPT is widely used through the Department of Veterans Affairs (VA) mental health sector and made widely available for use and implementation globally. They currently provide the following link, http://alrest.org/pdf/CPT_Manual_-_Modified_for_PRRP(2).pdf to the actual Veterans and Military CPT Manual (Resick, Monson, & Chard, 2008), being implemented in providing CPT treatment for PTSD through the United States Veterans Affairs healthcare system as well as other helpful instructional video series provided by the National Center for PTSD and the U.S. Department of Veterans Affairs here, http://www.ptsd.va.gov/professional/continuing_ed/flash-files/CPT/Player/launchPlayer.html?courseID=1568&courseCode=PTSD101_cpt specific to CPT implementation guidelines currently in effect.

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Blake, D. D., Weathers, F. W., Nagy, L. M, & Kaloupek, D. G. (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8(1), 75-90. doi: 10.1002/jts.2490080106.

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