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Responding to the Needs of Returning Veterans

July 6, 2011 by

Appropriate responses to the needs of returning veterans will include:
• A strength- and recovery-based focus
• An empowering, skill-training approach
• Careful, individualized, respectful, veteran-specific assessment and treatment planning
• A primary emphasis on stabilization and development of internal and external resources
• Education for veterans and families on the physical, cognitive and emotional aspects of trauma and substance use disorders
• Assertive linkage to ongoing support within the community—and in the larger military and veteran community nationwide
Effective responses to the needs of veterans with post-employment stress effects include a consistent approach that integrates trauma-informed addictions and mental health care, but what does that mean?  It means that when treating a veteran for mental and/or substance use issues the clinician must realize that the traumas experienced have changed how the person feels, reacts and perceives the world.  These changes are normal reactions to abnormal events.  Unfortunately, they often persist even when the danger is past.  This is the mind’s way of making sure the body survives. In order to help consumers to regain a sense of balance, we must create an environment of safety, trustworthiness, choice, collaboration and empowerment. 

Safety means ensuring physical and emotional safety not only in the treatment session, but also in veterans’ daily lives. Even Abraham Maslow believed that safety helped form the foundation of mental health and wellness.  When people do not feel safe, they are on guard, and they cannot rest well which negatively impacts their health, mood and relationships which could be supportive. So the next question I am often asked, is “What do they need protection from?”  They need places where they are not subject to judgement or evaluation, and are not concerned they will have to defend their actions or the actions of the military in general. If they have been deployed for a while, they need a community that can help them feel less like a stranger in a strange world.  They need places where people understand what they are going through, who have survived the nightmares, the insomnia and the feeling of utter isolation, not knowing who they can trust.  They need to learn the skills to deal with the flashbacks and the nightmares, and to relaxs at the end of the day.

Trustworthiness is developed in the process of creating safety by maintaining clear, appropriate, consistent boundaries and objectives.  Many people—veterans included—will not tell you everything until they believe you are trustworthy.  Those things that haunt them at 2am are not things they are going to tell just anybody.  Throughout the process that led to the PTSD–whether it be one single incident or years of traumas—the person regularly was stripped of their control, second guessed for every move and, often questioned on their decisions.   Trauma informed treatment not only relies on consumers learning to trust their therapists, but also on them learning to trust themselves.  Failure to keep promises reinforces the notion that the world is an unpredictable, terrifying place.  Failure to help consumers see the logic in what they did, or are doing, reinforces the notion that their behavior is unpredictable and they are out of control. Remember to ask yourself what the benefit is to any behavor. Our brains are programmed to survive.  How is the behavior helping the person survive. Substance abuse numbs pain and helps people survive until they develop alternate skills.  Fear reactions/fleeing protect the person from imminent danger.  Explosive anger can neutralize a perceived threat.

Choice means allowing consumers to prioritize what issues will be dealt with, when and to what extent. The caveat to this merges with collaboration.  While it is certainly advised to maximize consumer input and control, there are some things which may need to be negotiated. When consumers are putting themselves at risk, even before treatment starts, the chances of them engaging in highly dangerous behaviors when they are in the midst of a crisis is much greater. For example, if Johnny is drinking a fifth of whisky each night and chasing it with hydrocodone, I would certainly not recommend delving into deep, emotionally charged issues in a traditional outpatient environment.  It is likely when the pain increases, so will the desperation to stop the pain. Johnny first needs to get safe—mixing hydrocodone with whisky is just a slow way of committing suicide. If he can create a support plan that includes a drastic reduction in drinking (preferably 100%) and at least 3 people who will be there to support him, then I might consider working with him on the trauma issues in outpatient.  My preference is for people with dual disorders (i.e. PTSD and substance abuse) who live alone or do not have a strong support system to enter into either intensive outpatient or a 3-5 day retreat in which they can have 24-hour access to a therapist and have their medication and substance intake monitored. 

Finally, empowerment means providing consumers with the tools to help them create safety, trusting them to do the next right thing and encouraging them to make educated choices regarding their recovery and their life.  Empowerment means helping them find positive ways to use the energy they are currently using to try and contain their anger and devastation.  In PTSD, people often have a lot of “I should haves.”  They cannot change the past, but with the knowledge of what they believe they should have done, what can they do now?  That is to say, they cannot change the past, but what can they do to prevent it from happening in the future and/or make ammends if they believe they have done something wrong.

Trauma informed care identifies the trauma, and all of the associated mental, emotional, physical and social changes as the primary cause of people’s mental health and substance abuse issues.  Likely things will never be like they were before the trauma, but they can get better.  The terapists job is to help people define what “better” looks like, provide needed skills to help the person achieve their goals and empower them to start doing the hard work necessary to recover.

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Online Counseling for Anxiety, Depression and PTSD: Does it Work?

June 13, 2011 by

Over the past several years, online counseling has become more accepted in the mainstream counseling community.  Nevertheless, accepted does not necessarily translate to effectively used.  Let’s face it, some people just need to have the personal contact of being in a face-2-face session.  However, the vast majority of people are quite comfortable with video, phone or text chat.

 

Some of the benefits of online counseling for anxiety, depression, PTSD and addictions include:

  • Being able to connect with experts anywhere in the world
  • Access to services at the most convenient time for you (8pm on the East coast is 3 pm–still during normal business hours– on the West)
  • Reduced costs in terms of travel time, child care and waiting.  Instead of sitting in an uncomfortable waiting room, you can be watching ESPN in your living room.  This is especially important in areas like Atlanta, Arlington, Alexandria and Washington DC
  • Greater anonymity.  Some people do not want others to see them going in to see a counselor–for any reason.  Online counseling allows people to seek services for things like depression, anxiety and addictions in the privacy of their own home.
  • People with PTSD need to have a place they feel safe.  Practicing some of the exposure therapy techniques with an online counselor in the comfort of their own homes can help reduce their level of hypervigilence.
  • Does Fido make you feel more at ease?  Well, online counseling also enables you to have him in your lap.

 

What are some of the considerations for online counseling for people with depression, anxiety, addictions or PTSD?

  • Unless your issues are mild or moderate, many therapists will want to be able to chat with you via video such as Skype.  This allows us to better assess your mental status and level of danger to yourself or others.  In the case of addictions, video chat also allows the therapist to assess whether you are clean and sober.
  • For online video counseling you will need to have at least DSL internet.
  • If you select online counseling via text chat, it is important that you are able to type :)

 

What to expect at Gainesville-NOVA Counseling

  • Your first visit will consist of an intake assessment.  Your therapist will ask you a variety of questions to learn about who you are and what you hope to get out of counseling. She will probably give you three assignments.
    • Your first task will be to write an autobiography.  This will assist your counselor in understanding how you grew into the person you are today, when the problem started and what things make the problem worse and what things make it better. You will use a secure email account provided to you to email this to your counselor.
    • Your second task will be to keep a log of the problem (i.e. how many anger outbursts, how often you have flashbacks, on a scale from 1-5 what your average daily anxiety or depression rating was.
    • Pick on area of health to start working on: Getting sufficient, quality sleep; exercising, eating better or drinking more water.
  • During your second online counseling session, you and the counselor will review your autobiography, your problem log and the progress you have made in improving your health. Together you will develop a service plan to guide the online counseling process. This plan will use the knowledge-skills and abilities format.  Using cognitive behavioral therapy (CBT) you will be guided to learn more about the problem in general and specifically what triggers or improves your problem. Then you will identify skills that you already have which can help you deal with the problem, and enhance those.  Finally, your counselor will suggest some new skills to help you cope with or alleviate the problem.
  • Subsequent online counseling sessions will help you systematically go through the service plan, and make adjustments to it as necessary.
  • Our goal is to help you learn how to identify the root issues of your problems, increase your motivation to deal with them and use your current strengths and skills to achieve your highest quality of life.

In short, does online counseling for anxiety, addictions, depression or PTSD work?  It works if you work it.  If you just show up and expect the therapist to fix it for you, then I would not expect to see significant improvement.  If you treat counseling as a learning experience, to learn more about yourself and how people in general “tick,” then, yes, online counseling will probably work quite well.

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What Goes on Behind Closed Doors

June 12, 2011 by

Counseling can be very intimidating for people, so in the next few paragraphs we will take a look at what happens in the therapy room.

Okay, so first, there may be a couch, but that is usually to provide seating for multiple people (i.e. your spouse or family) if they come for a group session.   Most therapists these days do not expect you to lie down, nor talk about your mother.  Counseling in the 21st century usually involves one of two broad approaches.  The Rogerian approach is what most people think of when they envision counseling.  The thought is that if people are provided with a safe, nonjudgmental environment in which to explore their feelings, they will be able to identify and resolve their own issues.  This process takes more or less time depending on how long it takes to create that safety and how directive your therapist is.

The second approach is cognitive behavioral or CBT.  CBT is focused on 1) What is going well and not so well in the present, 2) What does the resolution to the problem look like, and 3) What steps need to be taken to get there.  While people’s past is important, because it has shaped who they are and how they view the world, the focus is on identifying (and maybe changing) how the past is impacting the person in the present.  CBT deals in facts, evidence and rational thought.  Many of the things we tell ourselves we must, should or can never do are good life lessons that have morphed into something irrational. To top it off, most people are depleting the energy needed for dealing with stress by not sleeping well, eating poorly and not exercising.  In most cases, the first steps are the most basic.  People need to start taking care of themselves and making one or two small changes in their attitude.

For example, Tom comes to counseling because he is totally stressed out and feels like he cannot do anything right.  Tom’s therapist might ask him what it is he hopes would be different if he were doing *everything* right.  She might point out that he seems to be holding himself to an unreasonably high standard, and would he hold his son to that same standard?  What would happen if his son failed to meet that standard?  Would it impact their relationship?  She might also ask him to identify one or two things that he feels he must be good at, and focus on doing those things right.  (Once that happens he loses the argument that he cannot do *anything* right).  She will probably also ask him to start trying to get at least 7 hours of sleep each night and walking his dog for 20 minutes each night after dinner.

Okay, so you get the idea, Rogerian tends to be more conversational and free flowing, CBT is much more directive, active and problem focused.  So why use one over the other?  Different people process things in different ways.  I am a therapist’s worst nightmare, because I need both.  When I am struggling with something, I want my feelings acknowledged, then I can go about the business of problem solving.  My husband, on the other hand, just wants to get down to business.   He figures the sooner the problem is solved, the sooner he will feel better.  Meanwhile, my best friend is one of those people who needs to talk about her feelings and use a therapist (or me) as a sounding board.

But is that all there is?  No, after all the talking comes the case notes.  You know, the secret stuff doctors write in people’s medical record that they do not think they are supposed to see.  Let me be the first to tell you that you have every right to see those.  I usually spend the last 10 minutes of the session writing them together with my patient.  Why?  Because it serves as a good summation of what we talked about, and then there is no mystery.  My job is to help people learn why they may be feeling or reacting in a certain way,  provide them the tools to better understand themselves and help them fix negative reactions/behaviors.  It is not magic.  Just like a mechanic can hear an engine hum and tell you volumes, so can a therapist hear what you are saying.  I could learn to be a mechanic, but I don’t really want to.  You could learn to be a therapist, but let’s start with listening to yourself first.

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Substance Abuse and the Veteran

May 31, 2011 by

We don’t know how many veterans will seek substance abuse treatment.  We do know that significant numbers of veterans may be avoiding treatment for fear of the stigma associated with postdeployment stress effects (Tanielian and Jaycox, 2008).  For many veterans who seek services, fear of having “mental health problems” or “substance abuse” attached to their service records may contribute to their decision to stay outside of all structures even remotely connected with the military. Experts at all levels agree that shame, stigma, and fear of military repercussions are significant blocks to help-seeking and recovery (Tanielian and Jaycox, 2008).

So let’s stop mincing words…are these soldiers weak or crazy?  No.  Absolutely not!  The connection between post-trauma effects and substance use disorders is well known. For example:

  • Between one third and one half of people seeking treatment for SUDs may also have posttraumatic stress disorder
  •  Having untreated PTSD has been associated with a more severe course and worse outcomes for substance use recovery.
    Drug dependence is frequent in war veterans with posttraumatic stress disorder (Alcoholism: Clinical & Experimental Research, 2008)
  • One preliminary study shows that “this generation of veterans has been much closer to trauma, has completed or may complete multiple tours of duty, and experience a greater prevalence of mental health issues (40%) and of those upwards of 60% also have a SUD” (Danforth, 2007, p. 11).

So why do veterans develop substance abuse issues?  Here are a few reasons…

  • When people respond to intense or unrelenting stress or threat, it often creates chemical imbalances that people instinctively try to deal with.  When “normal” coping skills fail to bring relief, people may seek sex, drugs, alcohol, food or gambling to numb or escape the pain.  Eventually the brain gets used to these substances and start to need more of them to get the same feeling of relaxation.  To compound this, the drugs or alcohol cause changes in the brain which may also lead to feelings of depression and/or anxiety.  Did you know that initially alcohol is a system depressant, but as it wears off, it causes symptoms of anxiety (fast heart rate, shortness of breath, dizziness, irritability)?
  • Many of the other aftereffects of war—from the neurological effects of trauma to the psychological and spiritual effects of exposure to death and destruction—can be very destructive.  Scientists are now doing imaging studies to show that people with traumatic brain injury often have similar brain changes as those who have been exposed to extreme trauma.  
  • It is important to remember a couple of things about trauma.  First, not everyone responds the same way to the same situations.  When we triage people after a crisis to identify who is more likely to develop PTSD, we look at if they have a history of mental health problems, how many stressors they have experienced in the last 6 months, how similar the person is to the victim, how close the event was, or how much of a threat the event posed to the safety of the person’s home, and how much positive social support they received immediately after the trauma. Secondly, when the alcohol and drugs that have “medicated” or numbed the memories leave the system, those stored memories and other symptoms of trauma can emerge at higher levels of intensity.
  • Injured veterans with pain-management needs are often prescribed opioid pain relievers (Vicodin, Lortab, Hydrocodone etc). Even in the absence of combat stress effects or prior histories of substance use problems, their injuries can leave them more vulnerable to dependence on those medicines.
  • Young male veterans with traumatic injuries may be more vulnerable to a number of risk-taking behaviors, including the misuse of alcohol, and less likely to seek or accept help for trauma and mental health issues (Good et al., 2008).  Part of this may be due to the mistaken notion that seeking help means they are weak, or believing counseling involves talking for hours on end about that “F” word…you got it….Feelings.

Substance abuse treatment providers have begun to focus on individualized treatment and recovery-based systems of care. It is imperative for these providers to receive specialized training in the specific needs and issues veterans face both in the field and at home.  Additionally, clinicians should use a comprehensive approach to helping the veteran in the areas of sleep hygiene, relationship issues, garnering social support, dealing with traumas and sheer exhaustion from being overstressed for an extended period and addressing problematic substance use behaviors.  Remember that the veteran may or may not be willing to address issues which he or she feels could come back to destroy their military career.  Provided the patient does not exhibit suicidal or homicidal ideation, the therapist may choose to present holistic interventions such as exercise, nutrition, time management, scheduling and sleep as adjuncts to assisting the person deal with “exhaustion” or “stress.”  For sustained recovery, people need to feel like they are not “the only one.”  They need to feel a connection with people who can relate to them (notice I did not say understand).  they need to have a safe zone where they can physically, mentally and emotionally relax.  And, they need to feel like what they do or have done has a worth and a purpose.

At Gainesville-NOVA Counseling, we provide a variety of services ranging from anonymous individual sessions to confidential group treatment.  While group therapy is excellent for treating substance abuse, some people do not want to be “exposed.”  What is most harmful not only to veterans, but also to their military and biological family is failing to have the courage to seek help.  While many vets come back in body, many leave their heart, soul and spirit on the battlefield.

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