Working with Veterans with Trauma and PTSD

Karen Krinsley, Ph.D.PTSD Section Chief,

VA Boston Healthcare System& PTSD Consultant,

National Center for PTSD

Presented April, 2012 as part of the Grant per Diem educational training series for staff

Outline of Talk

• Brief review of PTSD and implications of the diagnosis

• Barriers to getting help

• What makes PTSD symptoms better / worse?

• Practical ideas for helping

How can YOU help a Veteran with PTSD?

• Task: Think about what you do now

• What is working?

• What has been less helpful?

• Shared wisdom is the best!

• Comments welcome

Reminder: PTSD DiagnosisA Cluster of Symptoms

A Trauma (The “Stressor”)

B Reexperiencing / Intrusions

C Avoidance/Numbing

D Increased Arousal

E More than one month of symptoms

F Causes functional problems

Important to Remember

PTSD ≠ TRAUMA and

TRAUMA ≠ ANYTHING bad

Reminder: Implications of PTSD

• Greater risk of other disorders• 80% of people with PTSD have another diagnosis• Depression, SUD, Anxiety Disorders common

• Greater unemployment• Relationship difficulties• Health problems• Violence• Generally, worse quality of life

What About the Dually Diagnosed?

• Often seen as the most “undesirable” patients or residents

• Yet DD is extremely common!

• Helpful to understand how common it is

• Many of the DD’s are a function of/related to the PTSD

Substance Use as a Dual Diagnosis with PTSD

• May be Self medication (Substance Use)• To forget• To be able to feel and enjoy life• To keep going• To regain that adrenaline “high”• As self-punishment

• Becomes an independent Addiction

Other Diagnoses May Also Be Related to PTSD

• Connected to life circumstances and memories following the trauma (Depression)

• Additional symptoms related to the trauma (other Anxiety disorders)

Barriers to Getting Help

• Vets with PTSD (and others) are often unaware of their problems

• Problems may be obvious to those around them, but not to the Veterans

• It helps to understand how/why the Vets could truly be unaware

Reasons for Lack of Awareness of Problems

• Admitting problems = Weakness / Is Dangerous

• Trauma Symptoms/Responses feel right, e.g. isolating, avoiding, all or nothing thinking

• Lack of self worth and guilt = I don’t deserve to get better anyway

Additional Barriers to Getting Help

• Stigma – can you help reduce?

• Difficulty accessing

• Fear• What would it mean to get better? Is it

possible?• If I try to deal with this, I’ll start crying and

never stop• It’s too late

What Promotes Resiliency?

• Positive emotions, Emotion regulation, Cognitive flexibility, Coping style, Spirituality, Moral codeAND

• Social support

• Having resilient role models

• Purpose and meaning

What External Factors May Increase PTSD Symptoms?

• From Research:• Life Stress• Lack of Social Support

• More generally, anything that triggers memories or other symptoms

Common Triggers in Residential Settings – and Ways to Reduce

• TV Shows

• Conversation topics

• Disputes, Anger

• Disrespect

• Crowding

• Behavior of other residents, may be well-meant

Common Triggers in Residences, continued

• Not feeling safe at night• Locks?• Lights?• Noise (may or may not need)• Touching at night

• Required Outings

• What else?

Reminder: Consider a “Trauma-Informed Milieu”

• Structured but not authoritative or punishing

• Everyone treated with respect and listened to

• Setting is kept safe

• Staff aware that residents may be traumatized

Positive Steps To Take

• Always listen FIRST

• Start with support

• Take concerns seriously

• Treat everyone as an adult

Positive Steps, continued

• PTSD is an explanation (although not an excuse)

• Do ask if they want to talk and acknowledge their military service

• Don’t say “I understand”

• Be alert for risk issues

Helping Veterans with Anger Issues: Some Research

• Link between PTSD and violence is weak / unclear

• Veterans may get angry when exposed to trauma triggers

• Vets with PTSD may have elevated rates of intimate partner violence

Anger Findings, continued

• Hyperarousal symptoms are the most related to Anger and Aggression

• Alcohol use and Depression are risk factors for aggression

• TBI may be a risk factor

Anger Management: Useful Clinical Practice Guidelines

• Develop lists of enjoyable activities• And promote participation

• Promote sleep and relaxation

• Avoid stimulants and other substances such as caffeine and alcohol

• Address pain - highly linked to problems with anger and aggression

More Tips for Managing Anger

• Confrontation probably NOT helpful• Try to understand the cause, both to help

manage and to help yourself stay calm• Prepare ahead of time with the veteran if

possible• Allow “escape”

Helping Veterans with TBI (practical ideas)

• See “Anger”

• Organizational help may be needed• Small datebook / cell phone• Calendars, instructions in visible places• Alarms, reminders

Stress Management

• Can someone teach relaxation?

• If not, use tapes!

• Practice daily

Teaching Grounding

• Focus on the world around you

• Try an exercise with your staff

• Check out exercises in books

“Complementary and Alternative Medicines” (CAM) • Recommendations from our veterans

• Now being researched

• No clear proof yet, but individuals have found helpful

• Yoga

• Acupuncture

And Other Alternatives Recommended by Vets!

• Contact with animals

• Martial Arts

• Fishing

• Exercise

• Massage (be careful with this one)

• Reading / Self Help Books

• Journaling

Motivating Vets for Treatment

• Are there any role models?

• Instilling hope

• Encouraging but not forcing

• Ask: What is stopping you?

Professional Help - Reminder

• Know when to refer

• Be knowledgeable about PTSD treatments and aware that they work

• Encourage keeping appointments

• Acknowledge that it will be HARD but it is worth it

• Ask what the alternative is

• Be wary of splitting

Work with Therapists!

• The good ones welcome the opportunity

• Speak with veteran about a Release of Information

• Ask: What can we do to reinforce treatment?

• Ask: Anything we should be aware of?

• Working as a team is always better

More Information:National Center for PTSD Website

• www.ptsd.va.gov

• All types of information, for • Providers• Veterans• Families• General Public

• Has online courses such as “Understanding PTSD” and much more

PTSD Consultation Program Reminder

• One-on-one PTSD consultation for any VHA provider OR contractor

• Free of charge• Speak directly with “expert” PTSD

clinicians• Response usually within 24 hours• Easy to contact us: Call, email, or

complete an online form

Consultation Program Contact Information

Contact us:• Call 1 (866) 948-7880• Online Form at:vaww.ptsd.va.gov/consultation/ptsd_consult_req.asp

• Send e-mail to ptsdconsult@va.gov

Questions and Comments?